October 2005 Vol 3 No 5

back to issue contents

| back to Surgeon home

title
Langer's axillary arch: Anatomy embryological !eatures an" surgical im#lications

author$s%
I. Besana-Ciani M. J. Greenall Department of Surgery, Oxford ad!liffe "#S $rust, Oxford %& Corresponden!e to' M. J. Greenall Department of Surgery, (e)el *, Jo+n ad!liffe #ospital, Oxford ad!liffe "#S $rust, #eadley ,ay, Oxford O-. /D%, %& 0mail' isa1esana2+otmail.!om

abstract
(anger3s ar!+ is identified in up to 45 of axillary explorations6 in a t+ree-mont+ period 7e identified t+ree indi)iduals among forty-six patients undergoing axillary surgery 7it+ t+is a1normality. (anger3s ar!+ is a mus!ular-tendinous stru!ture t+at usually extends from latissimus dorsi to pe!toralis ma8or mus!le. $+e purpose of t+is arti!le is to des!ri1e t+e em1ryologi!al deri)ation of t+is mus!ular )ariant from t+e panni!ulus !arnosus and to define its anatomi!al features. $+e !lini!al impli!ations 1ot+ symptomati!ally and as an unexpe!ted finding during axillary disse!tion, are also dis!ussed &ey7ords' 9xillary anatomy, (anger3s ar!+ Surgeon, : O!to1er *;;< .*<-.*4 I"$ OD%C$IO" During t+e past t7o !enturies t+e anatomi!al )ariations of t+e axilla +a)e 1een des!ri1ed in 1ot+ text1oo=s of +uman anatomy and more re!ently in t+ose of operati)e surgery. Interest +as 1een furt+er stimulated 1y t+e in!reasing surgi!al importan!e of t+is region during axillary surgery for 1reast !an!er, re!onstru!tion te!+ni>ues and axillary 1ypass operations. $+e most !ommon mus!ular anatomi!al )ariation 7it+in t+e axilla is a mus!le extending from t+e latissimus dorsi mus!le to t+e pe!toralis ma8or mus!le, !alled )ariously (anger3s axillary ar!+, as!+els1ogen, axillope!toral mus!le, pe!todorsal mus!le or ar!us axillaris.:,* $+is anatomi! )ariation o!!urs in at least 45 of t+e population 1ut may not al7ays 1e !lini!ally apparent.:,. In a t+ree-mont+ period 7e identified t+ree indi)iduals 7it+ (anger3s ar!+ among forty-six patients, undergoing axillary surgery for 1reast !an!er ?@igure :A. $+e aim of t+is arti!le is to re)ie7 its anatomi! and !lini!al features as 7ell as its surgi!al impli!ations. 9"9$OMIC @09$% 0S ,+at is no7 !ommonly =no7n as t+e axillary ar!+ 7as first identified 1y 9lexander amsay in :4/< and su1se>uently dis!ussed in +is Account of Unusual Conformations of Some Muscles and Vessels pu1lis+ed in :B:*.C #e des!ri1ed Dan o1long mus!le, stret!+ed from t+e pe!toralis mus!le to t+e latissimus dorsi and teres ma8or, 7+i!+, in its )iolent !ontra!tions, must pro)e in!on)enient to t+e axillary arteries, )eins, and ner)es, 7+i!+ lie 7it+in t+is mus!le. It 7as not =no7n in 0din1urg+ or (ondon, 7+en I demonstrated it, and is no7 dete!ted in one of t+irty su18e!ts, 7+en disse!tors are

attenti)e.DC $+ere 7as little interest in amsayEs des!ription until (anger, in :BCF, des!ri1ed t+e mus!le more a!!urately, su!+ t+at t+ereafter it 1e!ame =no7n as D(anger3s ar!+D.* More re!ent !ada)eri! studies indi!ate t+e presen!e of t+e ar!+ in approximately 45 of indi)iduals, alt+oug+ some aut+orities +a)e reported a pre)alen!e of up to *45.:,*,< (anger3s ar!+ appears more !ommon among C+inese t+an in Cau!asians and is more !ommon in 7omen t+an in males.:,F It is usually 1ilateral, 1ut !an o!!ur unilaterally.< $+e em1ryologi!al deri)ation of (anger3s ar!+ remains un=no7n, 1ut t+e most relia1le t+eory supports its origin from t+e panniculus carnosus, 7+i!+ is an em1ryologi! remnant of a more extensi)e s+eet of s=in-asso!iated mus!ulature, lying at t+e 8un!tion 1et7een t+e superfi!ial fas!ia and t+e su1!utaneous fat.4 $+is stru!ture is 7ell de)eloped in lo7er mammals, parti!ularly rodents, 7+ile in +ig+er primates and +umans it is anatomi!ally e)ident only as mus!les su!+ as platysma and dartos6 in t+e remainder of t+e 1ody it 1e!omes )estigal.4,B In lo7er mammals t+e panni!ulus !arnosus is +ig+ly de)eloped to form t+e pe!toral group of mus!les. #o7e)er, in man it +as regressed 1e!ause its fun!tional importan!e de!reased during e)olution in fa)our of a 7ider upper lim1 mo1ility.B, In +umans (anger3s ar!+ is t+erefore t+e most !ommon em1ryologi! remnant of t+e panni!ulus !arnosus in t+e pe!toralis group of mus!les, alt+oug+ it !an o!!ur as ot+er rare mus!ular )ariations t+at in!lude pe!toralis >uartus, intermedius and sternalis. ,+en t+is )estigal stru!ture is present, it arises from t+e latissimus dorsi and extends )aria1ly a!ross t+e axilla as mus!ular or tendinous 1undles, 1ut sin!e it +as no fun!tional signifi!an!e, many )ariations in origin, insertion, !ourse and siGe may o!!ur.:,F $+e pre)alen!e of pe!toralis >uartus may 1e as +ig+ as :F5 alt+oug+ it is rarely identified6 its !om1ination 7it+ (anger3s ar!+ is less fre>uent ?/5A. ,+en t+is !om1ination o!!urs, pe!toralis >uartus is usually inserted into t+e inferior 1order of (anger3s ar!+.: (anger3s ar!+ typi!ally originates from latissimus dorsi eit+er as a mus!le 1undle or as a tendon6 ex!eptionally it arises from serratus anterior. ,+et+er (anger3s ar!+ is mus!ular or tendinous depends on 7+et+er t+e pe!toralis ma8or mus!le or t+e tendon of latissimus dorsi !ontri1utes most to its formation, respe!ti)ely.:,< (anger3s ar!+ usually is seen as a single 1and, 1ut it !an di)ide into dou1le or, rarely, multiple stru!tures 7+i!+ extend a!ross t+e axilla. In its !omplete and !ommon form it arises from latissimus dorsi and inserts into t+e trilaminar tendon of pe!toralis ma8or on t+e +umerus, 7+ile in its in!omplete form it presents 7it+ )arying insertions into pe!toralis minor, !ora!o1ra!+ialis, long or s+ort +eads of 1i!eps, teres ma8or, !ora!oid pro!ess, first ri1, axillary fas!ia or !ora!o1ra!+ial fas!ia.:,.,:; $+e 1lood supply to (anger3s ar!+ is deri)ed from t+e lateral t+ora!i! )essels, 7+ile its inner)ation is pro)ided 1y t+e t+ora!odorsal ner)e, t+e !audal pe!toral ner)e or 1y perforating 1ran!+es of t+e se!ond and t+ird inter!ostal ner)es. Its !ontra!tion promotes ele)ation and a1du!tion of t+e upper lim1 1ut +as minor fun!tional importan!e.:,.,< Despite its many anatomi! )ariations, a Japanese study on /C axillary !ada)eri! disse!tions re!ently attempted to !lassify (anger3s ar!+ into t7o groups, $ype I ?mus!ular stru!tureA and $ype II ? tendinous stru!tureA, ea!+ in!luding four different su1-types depending on ner)e supply and site of insertion./ C(I"IC9( 9"D S% GIC9( IMH(IC9$IO"S (anger3s ar!+ !an o!!asionally 1e palpa1le during routine !lini!al examination 7+en, presenting as an axillary mass, it !an 1e !onfused 7it+ enlarged lymp+ nodes or soft tissue tumours. Clini!al features su!+ as intermittent axillary )ein o1stru!tion or a finding of fullness 7it+in t+e axilla itself !an 1e !lini!ally useful 1ut an M I s!an may 1e re>uired to !onfirm t+e diagnosis.<,:: It +as 1een reported to !ause axillary )ein entrapment and, more rarely, lymp+ati! !ompression 7it+ su1se>uent )enous t+rom1osis or lymp+oedema 1e!ause of its !lose relations+ip 7it+ neuro)as!ular and lymp+ati! stru!tures 7it+in t+e axilla. It +as also

1een impli!ated as a !ause of t+ora!i! outlet o1stru!tion and s+oulder insta1ility syndrome 1e!ause of neuro)as!ular !ompression 7it+in t+e !er)i!o-axillary region..,<,:* (anger3s ar!+ is usually asymptomati! and its main importan!e is t+e !onfusion it !an !ause during routine axillary surgery for 1reast !an!er. $+e presen!e of mus!ular or tendinous fi1res of t+e ar!+ !an impede ade>uate exposure of t+e true axillary fat and in parti!ular may limit a!!ess to t+e lo7er lateral group of lymp+ nodes, t+us resulting in an in!omplete !learan!e of t+e axilla. @urt+ermore, t+e identifi!ation of (anger3s ar!+ or its remnant may 1e of parti!ular importan!e 7+en performing sentinel node 1iopsy, 1e!ause of t+e need for ade>uate exposure and good +aemostasis during t+is pro!edure..,:. 9lt+oug+ lymp+ node disse!tion for 1reast !an!er is t+e most !ommon type of surgery performed in t+e axilla, t+ere are ot+er surgi!al pro!edures in t+is area, 7+i!+ may 1e effe!ted if (anger3s ar!+ is en!ountered. 9!!ess for 1ypass surgery using t+e axillary )essels may 1e !ompromised if t+ere is failure to identify (anger3s ar!+.:C Is!+aemi! ne!rosis +as !ompli!ated latissimus dorsi 1reast re!onstru!tion if t+e t+ora!odorsal pedi!le is stret!+ed or !ompressed 1y an unsuspe!ted axillary ar!+.:< (anger3s ar!+ may 1e a dire!t relation of t+e axillary stru!tures, su!+ as t+e t+ora!odorsal neuro)as!ular 1undle, t+e 1ra!+ial plexus, t+e lateral lymp+ati! trun=s or t+e axillary )ein. $+ese stru!tures may 1e at ris= if t+e presen!e of (anger3s ar!+ is not !onsidered, leading to 1leeding or ner)e damage. Inade>uate disse!tion may also predispose to ex!essi)e lymp+ati! disruption and !onse>uent lymp+oedema..,:. CO"C(%SIO" It is important t+at surgeons operating in t+e axilla are a7are of t+is not un!ommon anatomi!al )ariant. ,+en present, (anger3s ar!+ s+ould al7ays 1e a!!urately identified and formally di)ided to allo7 ade>uate exposure of axillary !ontents in order to a!+ie)e a !omplete lymp+ati! disse!tion and preser)e )as!ular, lymp+ati! and ner)ous stru!tures. Copyrig+t / May *;;<