Management of Accessory Nipple (Polythelia) in the Elderly
In elderly patients with accessory nipples, observation is appropriate for asymptomatic lesions, while surgical excision should be performed if there are symptoms (pain, discharge, cosmetic concerns) or if the lesion contains glandular tissue that could harbor malignancy.
Clinical Assessment
When evaluating an accessory nipple in an elderly patient, focus on:
- Location: Most commonly found along the embryonic milk line (from axilla to groin), with axillary and chest wall locations being most frequent 1
- Symptoms: Pain, restriction of movement, discharge, or cosmetic distress 2
- Associated tissue: Determine if there is underlying glandular breast tissue (polymastia) versus isolated nipple (polythelia)
- Ipsilateral breast status: 7.6% of patients with polythelia have concurrent malignancies in their native breast 1
Diagnostic Workup
The histopathological composition matters significantly for management decisions:
- Clinical examination alone is often insufficient—what appears to be an accessory nipple may actually be a nevus (48.1%), seborrheic keratosis (13.0%), or hemangioma (3.7%) 1
- Ultrasound should be performed if there is palpable tissue beneath the nipple to identify glandular components
- Biopsy consideration: If glandular tissue is present, the same pathological processes affecting normal breasts can occur, including malignancy 3
Management Algorithm
For Isolated Polythelia (Nipple Only, No Glandular Tissue):
- Asymptomatic: Observation is acceptable 1
- Symptomatic or patient anxiety: Surgical excision for diagnosis confirmation and symptom relief 2
For Polythelia with Underlying Glandular Tissue:
Surgical excision is recommended because 3:
- The tissue is subject to the same pathological lesions as normal breast tissue
- Potential for malignant transformation exists
- One case of ductal carcinoma in situ has been documented in polymastia tissue 1
In the elderly population specifically, a 72-year-old male case demonstrated that long-standing accessory breast tissue can progressively enlarge and cause functional impairment, with successful outcomes following surgical removal 4.
Surgical Approach
When excision is indicated:
- General anesthesia is standard 2
- Z-shaped incisions provide better cosmetic outcomes (used in 25% of cases) 2
- Complete excision of all glandular tissue is essential
- Histopathological examination is mandatory to exclude malignancy 1, 2
Common Pitfalls
- Misdiagnosis: Nearly half of clinically suspected accessory nipples are actually other benign skin lesions 1
- Incomplete evaluation: Failing to assess for underlying glandular tissue before deciding on observation
- Ignoring ipsilateral breast: Not screening the native breast when accessory tissue is identified
Postoperative Considerations
Expected complications are manageable:
- Wound dehiscence: 9.37% of cases 2
- Lymphedema: 6.25% of cases 2
- Both resolve with conservative management
The key distinction in elderly patients is that while polythelia alone may be observed, any associated glandular tissue warrants excision due to malignant potential, regardless of age.