Original article

In vivo study of the surgical anatomy of the axilla

A. Khan, A. Chakravorty and G. P. H. Gui
Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
Correspondence to: Mr G. P. H. Gui (e-mail: gerald.gui@rmh.nhs.uk)

Background: Classical anatomical descriptions fail to describe variants often observed in the axilla as they
are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections.
The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to
document the nature and frequency of these anatomical variations based on in vivo peroperative surgical
observations.
Methods: Detailed anatomical relationships were documented prospectively during consecutive axillary
dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence
of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching
of the intercostobrachial nerve were recorded.
Results: Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical
variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients
(14 per cent) – three variants; lateral thoracic vein in 12 patients (16 per cent) – four variants; bifid
axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and
variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein,
a subscapular vein tributary, was found to be a constant axillary structure.
Conclusion: Variations in axillary anatomical structures are common. Poor understanding of these
variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned
microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be
aware of the common anatomical variants to facilitate efficient and safe axillary surgery.

Presented in part to a meeting of the Association of Surgeons of Great Britain and Ireland, Liverpool, UK, April 2010;
published in abstract form as Br J Surg 2010; 97(Suppl 2): 12–13
Paper accepted 17 February 2012
Published online 16 April 2012 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.8737

Introduction Despite the frequency of axillary dissection, comprehen-

In an era in which sentinel lymph node biopsy (SLNB)
has become the standard of care, the role of primary
axillary dissection has become confined to the surgical
management of the lymph node-positive axilla identified
by preoperative ultrasound staging and needle sampling,
or a positive SLNB at intraoperative assessment. A
node-positive axilla or completion axillary dissection at
re-exploration following a previously unexpected positive
SLNB may pose significant operative technical challenges.
In these patients access to achieve complete surgical
clearance, defining anatomical boundaries and identifying
key landmarks to preserve vital structures often become
more challenging.
sive anatomical descriptions of the axilla and the common
variants are lacking in standard texts of anatomy and opera-
tive surgery. A clear understanding of the surgical anatomy
is essential for the surgeon to achieve complete resec-
tion, minimizing morbidity from avoidable injury to easily
recognizable soft tissue structures. Some recent studies
have examined the anatomy of individual structures of
interest in isolation1 – 9 . However, few investigations have
considered the relationship of the key structures to each
other, in particular from the viewpoint of the operating
surgeon10 .
In this study, the detailed course and anatomical variants
of some of the principal structures in the axilla were
explored in a consecutive series of patients undergoing
axillary dissection for stage II or III invasive breast cancer.

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Published by John Wiley & Sons Ltd
872
Methods
Detailed anatomical relationships between key structures
encountered during consecutive axillary dissections were
documented. Axillary dissection was performed en bloc
in conjunction with a mastectomy. In breast-conserving
surgery, the operation was performed either through
the same incision used to access the breast or via a
separate axillary incision. A level III axillary dissection
was performed, including the nodes medial to pectoralis
minor as the apex of the resection specimen.
Data were collected prospectively from surgical findings
immediately after each operative procedure. In particular,
the course and relationships of the thoracodorsal (TD)
pedicle, lateral thoracic vein (LTV), venous drainage of
the accessory axillary veins and angular vein, latissimus
dorsi (LD) muscle slips, and the origins and branching of
the intercostobrachial nerve (ICBN) were recorded and
compared with standard descriptions of axillary anatomy,
as detailed below.
Thoracodorsal pedicle
The TD pedicle comprises the TD nerve (TDN), vein
(TDV) and artery (TDA). The TDN originates from the
posterior cord of the brachial plexus and innervates the
LD muscle. Standard texts describe the TDN as arising
beneath the axillary vein medial to the subscapularis vessels.
As the nerve descends to enter the LD muscle, it crosses
to lie in front of the artery (which at this level is called
the TDA), before passing lateral to the vessels to penetrate
the LD muscle11,12 . In a study of 100 axillary dissections,
Kutiyanawala and colleagues10 found a variant in 5 per cent
of patients, in whom the TDN was found to arise medial or
posterior to the subscapular vessels and remain in a medial
or posterior position until entering the LD muscle. This
configuration was also documented by Chan and Tan3 in a
study of 40 axillary dissections.
The TDV courses superiorly on the anterior surface of
the subscapularis muscle and becomes the subscapular vein
(SSV) before draining into the axillary vein. Textbooks of
anatomy and operative surgery11 – 18 and other literature
documented no variants of the TD vessels from what is
considered the standard anatomy.
Lateral thoracic vein
The LTV is a tributary of the axillary vein, which drains
the breast, pectoralis major and serratus anterior. The
arrangement usually displayed in standard texts of anatomy
and operative surgery shows the LTV draining directly
into the axillary vein anteromedial to the TD pedicle11 – 18 .
 2012 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
A. Khan, A. Chakravorty and G. P. H. Gui
There are no studies or texts documenting variation in
LTV drainage into the axillary vein.
Accessory axillary vein
The axillary vein is a continuation of the basilic vein and
originates at the lower margin of teres major. One study
documented a variant in axillary vein anatomy; 10 per cent
of patients were found to have a double or accessory axillary
vein running in parallel10 .
Angular vein
The angular vein, a tributary of the SSV, was described
by O’Rourke and Layt in 19932 ; the angular vein was
found to be present in 95 per cent of axillary dissections.
Demonstrated to arise from the scapular anastomosis, the
angular vein was described to pass superolaterally to join
the TDV to form the SSV. A subsequent study of 40
patients by Chan and Tan3 corroborated this description
and found the angular vein to be present in all 40 patients.
Latissimus dorsi muscle slips
Variation in the attachments of the LD muscle has been
documented in anatomical texts and other literature.
These variants have been described using a range of
terms, most commonly ‘Langer’s axillary arch’, ‘muscular
axillary arch’ or ‘LD muscle slips’5 – 7,11 . The frequency
of these variant muscle slips is likely to be population-
dependent; most authors cite a frequency of between 0·25
and 13 per cent5 – 7 .
Intercostobrachial nerve origins and branching
The ICBN is a sensory nerve that innervates the posterior
and medial parts of the upper arm and axilla. Textbooks
of anatomy describe the ICBN as the lateral cutaneous
branch of the second intercostal nerve (T2), but also
document that the lateral cutaneous branch of the third
intercostal nerve (T3) can contribute to the ICBN12 – 14 .
The standard description of the course of the ICBN within
the axilla is of a single branch passing from medial to
lateral. Any branching of the ICBN within the axilla is not
well documented11 – 18 .
Results
Of the 73 axillary dissections performed in this study, 71
were carried out in women and two in men. There were
37 right-sided and 36 left-sided axillary dissections. The
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Surgical anatomy of the axilla 873

median patient age was 53 (range 32–86) years. Among a
total of 73 axillary dissections, 43 (59 per cent) revealed at
least one anatomical variant.
Thoracodorsal pedicle
Thoracodorsal nerve
In 63 axillary dissections (86 per cent), the TDN arose
beneath the axillary vein medial to the subscapularis vessels,
and crossed these vessels to lie in front of the TDA as
it descended to enter the LD muscle. In seven patients
(10 per cent), the TDN initially originated medially, then
passed posterior to the vessels to lie lateral to them before
entering the LD muscle. A less common variant was seen in
three patients (4 per cent), in whom the TDN arose medial
or posterior to the subscapular vessels and remained in a
medial or posterior position until entering the LD muscle
(Fig. 1).
Relationship of thoracodorsal artery to vein
In 68 patients (93 per cent), the TDA coursed posterior to
the TDV with the vein passing from an anteromedial to
an anterolateral position. In the remaining five patients
(7 per cent), the TDA was found to lay posterolateral
to the vein throughout the entire course (Fig. 1). The
TDV courses superiorly on the anterior surface of the
subscapularis muscle and becomes the SSV before draining
into the axillary vein at its posterior–inferior surface. This
anatomical site of entry distinguished it from other venous
drainage into this segment of the axillary vein because other
vessels such as the LTV drained into the inferior border
of the axillary vein having coursed superiorly suspended in
the fat of the axilla anteromedial to the TD pedicle (Fig. 2).
Venous anatomy
Lateral thoracic vein
Four variants in the anatomy of the LTV were identified
and classified into types 1–4 (Fig. 2). In type 1, the
most commonly encountered variant affecting 61 patients
(84 per cent), the LTV drained directly into the axillary
vein anteromedial to the TD pedicle.
In the type 2 variant, found in seven patients
(10 per cent), the LTV joined the SSV to form a common
pedicle before draining into the axillary vein. The anterior
branch of the pedicle was found to be the LTV and
the posterior branch the SSV. The type 3 variant, in
three patients (4 per cent), had a trifurcating branch of the
axillary vein where the central branch was the LTV, the
medial branch arose from the chest wall or pectoral vein
and the lateral branch rejoined the axillary vein. The rarer
type 4 variant, observed in two patients (3 per cent), was
similar to type 3 but without the lateral branch rejoining
the axillary vein (Fig. 3).

Observed
frequency (%)

Lateral Medial
Cranial Type 1 84 (61 of 73)
AV

TDA SSV LTV

Type 2 10 (7 of 73)
LTV clipped
AV
TDV
SSV LTV
TDN
Type 3 4 (3 of 73)
AV
Arises from chest
wall/pectoral vein
LTV

Fig. 1Right axillary dissection showing a thoracodorsal nerve Type 4 3 (2 of 73)

(TDN) variant. The TDN lies in a posteromedial position to the AV
thoracodorsal vein (TDV) until entering the latissimus dorsi LTV Arises from chest
muscle. The thoracodorsal artery (TDA) lies posterolateral to wall/pectoral vein
the vein through the entire course. The figure also demonstrates
the type 2 variant of the lateral thoracic vein (LTV); the Fig. 2 Diagram demonstrating the four anatomical variants of the
subscapular vein and LTV join to form a common pedicle that lateral thoracic vein (LTV) and their frequency. AV, axillary
drains into the axillary vein vein; SSV, subscapular vein

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874 A. Khan, A. Chakravorty and G. P. H. Gui

Cranial
Cranial
AV

Chest wall perforator

LTB AnV

LTV

SSV
ICBN

TDN

Fig. 3Left axillary dissection showing a type 4 lateral thoracic

vein (LTV). The LTV joins the chest wall or pectoral vein to Fig. 4Left axillary dissection showing variant angular vein
form one common pedicle that drains into the axillary vein (AV). (AnV). The thoracodorsal nerve (TDN) arises medial to the
ICBN, intercostobrachial nerve subscapular vein (SSV) and crosses it anteriorly to lie lateral to it.
At this junction the AnV joins the SSV. A second AnV lies
parallel and inferior to the first. By following the AnVs medially,
Axillary vein the long thoracic nerve of Bell (LTB) is identified
On axillary dissection, ten patients (14 per cent) were found
to have a double axillary vein. Of those with a double
Observed
axillary vein, three patients also had variants in at least one
frequency (%)
other venous structure in the axilla.
Lateral Medial
Type 1 74 (54 of 73)
Angular vein
The angular vein was found to be a constant structure,
Type 2 18 (13 of 73)
present in all axillary dissections performed in this study. A
double angular vein was found in 18 patients (25 per cent)
(Fig. 4). The second angular vein, when present, like the
principle angular vein drained into the collateral circulation
Type 3 3 (2 of 73)
of serratus anterior on the lateral chest wall. Irrespective
of the presence of the second angular vein, the TD vessels
continued on their course inferomedially on to the anterior
surface of the LD muscle.
Type 4 3 (2 of 73)

Latissimus dorsi muscle slips

An axillary arch or LD muscle slip was present in four
axillary dissections (5 per cent). In two of these patients,
the arch extended from LD to pectoralis major. In one
patient, the muscle arch linked LD to pectoralis minor,
and in the remaining patient the arch connected LD to the
coracoid process.
Intercostobrachial nerve origin and branchings
In 66 patients (90 per cent) the ICBN originated from T2
alone, in two patients (3 per cent) from T3 alone, and in
five patients (7 per cent) it originated from a combination
of T2 and T3.
Type 5 3 (2 of 73)
Fig. 5Diagram showing the branching patterns of the
intercostobrachial nerve in the axilla and their frequency
The ICBN existed as a single branch while in the
axilla in 54 axillary dissections (74 per cent). In 13 patients
(18 per cent), the ICBN divided into two branches while in
the axilla. Three less common variants noted were: a single
branch of the ICBN dividing into more than two branches
in the axilla (2 patients, 3 per cent); two or more branches
merging to form a single branch in the axilla (2 patients,

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Surgical anatomy of the axilla
3 per cent); and two or more branches merging to form a
single branch, but rebranching again within the axilla to
form two or more distal branches (2 patients, 3 per cent)
(Fig. 5).
Discussion
As SLNB has become an accepted method for stag-
ing the axilla, the role of axillary dissection is usually
in the surgical treatment of established node-positive
disease. False-negative tests arising from intraoperative
assessment of the sentinel node occur, and a second
surgical procedure to the axilla after definitive histol-
ogy is recommended in up to 5 per cent of women19 – 23 .
In centres where intraoperative assessment of SLNB is
not possible, a positive result often leads to the rec-
ommendation for a second axillary procedure. Recur-
rent disease in the axilla after failed primary treatment
can also lead to a recommendation for repeat axillary
dissection.
The second surgical procedure is often more technically
demanding. A sound knowledge of the axillary structures
enables the surgeon to approach the complex axillary
dissection from different directions. In a heavily involved
axilla with nodes in upper level 2 that obscure visualization
of the axillary vein, a lateral approach with initial
identification of the TD pedicle can be helpful.
Damage to the TD vascular pedicle or the nerve to LD
may restrict the option of a LD flap breast reconstruction,
or for chest wall resurfacing should there be future
extensive local cancer recurrence. The relationships of
the TDA to the TDV are of particular relevance to
the microvascular surgeon as recipient vessels. The less
common variant of the TDN described in the present
study, where the nerve maintains its medial or posterior
relationship to the vessels until entering the LD muscle,
has been reported previously3,10 . The passage of the TDN
from an initially medial position to posterior to the vessels
to lie lateral to them before entering the LD muscle,
however, is an original finding.
The present study recorded four variants of the
LTV. Although this structure is often divided during
axillary surgery, with advances in microvascular procedures
preservation of the LTV may prove to be a useful tool.
Chand and colleagues24 described the use of the LTV as a
salvage option in a deep inferior epigastric perforator flap
when the blood supply to the flap was at risk. The type 2
variant of the LTV poses a particular risk for iatrogenic
injury by the inexperienced surgeon, who may sacrifice
what seems to be the LTV but is actually the common
pedicle formed by the SSV and LTV before joining the
 2012 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
875
axillary vein. This could lead to the disruption of venous
outflow from the LD muscle.
The axillary vein serves as a landmark to define the upper
limit in an axillary dissection. One study reported bifid
axillary veins in 10 per cent of patients10 , compared with
14 per cent in the present study. Iatrogenic injury to this
structure can cause significant haemorrhage, particularly
in a bifid system. Inadvertent ligation of the axillary vein
or its bifid branch can compromise venous outflow from
the arm and contribute to postoperative arm swelling or
lymphoedema10 .
The angular vein, a tributary of the SSV, has been
described previously in three smaller studies, and has
three important clinical applications2 – 4 . First, the angular
vein can be used to define the inferior limit of axillary
dissection. Second, the long thoracic nerve can be identified
by following the angular vein towards the chest wall.
Finally, the TDN can be identified in proximity to the
confluence of the angular vein with the TDV in forming
the SSV2 – 4 . A double angular vein was identified in 18
patients (25 per cent) in the present study. This is in
contrast to the findings of O’Rourke and Layt2 who
reported double angular veins in only 5 per cent of patients,
and Chan and Tan3 who did not mention the presence
of double angular veins. The angular vein represents
a collateral circulation between the TD and serratus
anterior systems, and should be preserved to ensure good
venous drainage from the trunk, especially after LD flap
reconstruction.
The presence of LD muscle slips is not a rare
variant. Their recognition improves access to the axilla
by allowing surgeons to divide these muscle anomalies
confidently. Lymph nodes lying posterior and lateral
to these unexpected muscle slips could be missed by
an inexperienced surgeon. If the axillary muscle arch
is mistakenly thought to be the free edge of the LD
muscle, the dissection could inadvertently be taken higher
than the axillary vein resulting in potential injury to the
axillary artery or brachial plexus5 . The unwary surgeon
may also damage the TD pedicle if the muscle slips are
divided too close to the LD, affecting immediate or delayed
reconstructive options.
ICBN division commonly results in sensory loss of the
floor of the axilla, extending as a strip of numbness down
the upper medial arm. ICBN damage can result in pain and
paraesthesia, potentially contributing to shoulder stiffness
and a prolonged recovery from surgery25 – 28 . The origins
and branching of the ICBN have been shown to be highly
variable8,9 . In the present study only 47 axillas (64 per cent)
conformed to the standard description, with the ICBN
originating from T2 alone and existing as a single branch in
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876
the axilla. In 66 patients (90 per cent), the ICBN originated
from T2 alone, in agreement with the findings of Cunnick
and co-workers8 . Loukas and colleagues9 reported that
73 per cent of ICBNs originated from T2 alone, but
that 25 per cent were formed by a combination of T2
and T3. In Cunnick and co-workers’ investigation, no
ICBN arose from T3, whereas 9 per cent originated from
a combination of the first intercostal nerve (T1) and T2.
Loukas and colleagues reported that 2 per cent of ICBNs
originated from T2, T3 and the fourth intercostal nerve.
In the present study T1 did not contribute to the ICBN.
A notable observation in some patients was that, when
the fourth lateral intercostal vessels were accompanied by
large intercostal nerves to supply cutaneous sensation to
the lateral chest wall and axillary floor, a separate ICBN
was also identified. It is postulated that these are distinct
levels of segmental innervation of the lateral trunk, axillary
floor and the medial upper limb.
The ICBN was found to exist as a single branch while in
the axilla in 54 axillary dissections (74 per cent), in contrast
to 51 per cent reported by Cunnick and co-workers8 . In
13 dissections (18 per cent) the ICBN divided into two
branches while in the axilla. The frequency of ICBN
variants, in terms of both of their origins and their
branching patterns, may explain why some randomized
trials comparing division versus preservation of the ICBN
have shown no significant difference in paraesthesia or
pain29,30 .
Variations in axillary anatomy are common but poorly
described in the literature. Detailed knowledge of the
axillary anatomy facilitates safe and thorough surgery, often
in an axilla previously treated by surgery, radiotherapy or
in the presence of cancer recurrence.
Disclosure
The authors declare no conflict of interest.
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