Akademik Veri Yönetim Sistemi
ESPRAS Quadrennial Congress 2022, Porto, Portekiz, 5 - 07 Ekim 2022
OUR HOLİSTİC APPROACH İN POLAND SYNDROME
Dokuz Eylul University Faculty of Medicine, Department of Plastic, Reconstructive and
Aesthetic Surgery, Izmir
Introduction: Poland syndrome was described by Alfred Poland in 1839. It occurs as a result
of the subclavian artery not developing in the embryological period. The pectoralis major
muscle has components such as absence of the sternocostal part or all, absence of the
pectoralis minor muscle, hypoplasia of the breast and chest wall structure, absence or
hypopigmentation of the nipple, brachydactyly. In its heavy forms, the costochondral
cartilage, sternum and 2-4. costae may not be found. Treatment is planned according to the
severity of the syndrome.
The pedicled latissimus dorsi flap, one of the first described treatment options, is frequently
used in the reconstruction of chest wall and breast deformities. Deep inferior epigastric
artery perforator (DIEP), anterior lateral thigh (ALT), transverse myocutaneous gracilis (TMG)
or transverse rectus abdominis for autologous breast reconstruction There are free flap
options that require microsurgery, such as myocutaneous (TRAM). Other options available
for reconstruction include autologous fat grafting, tissue augmentation, and breast implants.
Unfortunately, a personalized treatment concept is key in most cases, as every procedure
has risks and limitations that need to be well-balanced. In this article, we will discuss the
personalized treatments we apply in patients with Poland syndrome who applied to us for
chest reconstruction in the light of the literature.
Material-Method: This study was performed on patients who underwent chest
reconstruction due to Poland syndrome in the plastic surgery clinic of Dokuz Eylul University
Hospital between January 2003 and January 2022. Patients were retrospectively screened
through system records. All patients; Age, gender, the side of Poland syndrome, the
presence of additional anomaly, and the reconstruction technique applied were recorded.
Surgical procedures performed on the side not affected by the syndrome to correct the
breast asymmetry were also recorded.
Results: Twenty-four patients, 3 (12.5%) male, 21 (87.5%) female, with an age range of 17-41
years, were included in the study. A total of 31 breasts were treated. The mean age was 19.3
years.
While it was observed on the right side in 15 (62.5%) of the patients, the left side was
syndromic in 9 (37.5%) patients. Brachysyndactyly was observed in 4 (16%) of the right side
syndromic patients. Due to gynecomastia on the left side, liposuction on the left side, gland
excision with infraareolar crescentic incision, and right chest reconstruction with fat graft
taken from the abdomen were performed. Fat graft was applied to one patient with left-
sided syndromic. Reconstruction was performed with a pedicled latissimus dorsi flap in the
other patient with right-sided syndromic.
Augmentation was performed with unilateral silicone implant in 7 (33%) of the female
patients, and bilateral silicone implant was applied in 6 (28%) patients. Silicone implant was
placed in 4 (19%) patients after tissue expander application. 3 (14%) silicone implants were
placed on the syndromic side of the patient, while reduction mammoplasty operation was
performed on the opposite side.After the pedicled latissimus dorsi muscle flap was applied
to 1 (5%) patient, sufficient volume was provided with tissue expander, then a silicone
implant was placed.
In one patient who was repaired with a unilateral implant, prosthesis removal operation and
antibiotic therapy were performed due to the development of wound infection. The patient
whose clinical condition stabilized was re-implanted. Lipofilling was applied twice to 1 of the
patients who had a unilateral prosthesis.No early (hematoma, seroma, wound dehiscence,
etc.) and late period (capsule contracture, malposition, etc.) complications were observed in
other patients with prosthesis. Additional surgical intervention was not required in patients
who were reconstructed with other options.
Discussion: Although Poland's syndrome is a rare anomaly, it is an anomaly that creates
problems both aesthetically and functionally. Existing malformations can cause severe
psychological disorders. Sometimes the deformity is so serious that deterioration in heart
and lung functions may occur. However, patients primarily desire to have an aesthetically
normal or near-normal appearance, as dysfunctions that are not severe are compensated
over time. In cases where the existing deformity is severe and complicated, successful
results have been obtained by using different methods together.
There are options that can be prepared from the patient's own body and used as a free or
pedicled flap for the correction of chest wall deformity or the repair of the missing pectoralis
major muscle with a functional muscle transfer. The most commonly and effectively used
transfer is the transfer of the latissimus dorsi muscle to the pectoralis major muscle in the
form of an island flap on the thoracodorsal artery and vein pedicle and by protecting the
thoracodorsal nerve. However, sometimes the latissimus dorsi muscle is also affected by the
deformity and may be hypoplasic or aplasic. Therefore, when considering the latissimus
dorsi muscle for reconstruction, the degree of its adequacy must be evaluated very well.
Implants offer the most commonly used surgical technique, easy and fast options for repair.
Although the results of customized implants are generally good aesthetically, the long-term
effects of foreign bodies and their inability to adapt to changes in the patient's body have
proven to be a disadvantage. Malposition and seroma are the most common complications.
While there are rates of up to 30% of early-stage seroma in the literature, there is little
reported data on late-onset chronic seroma.
Autologous free fat transfer (lipofilling) is now widely used as a stand-alone treatment for
structural tissue deficiencies or in combination with other procedures such as implants or
pedicled and free flap reconstructions.
Since the breast requirements of male and female patients are different, the path to be
followed is different. In male patients with mild deformities, lipofilling treatment is used to
eliminate the missing breast volume and deformity in the axillary fold. Performing this
procedure in patients with gynecomastia in the same session will increase patient
satisfaction.
Adequate reconstruction of the female breast has proven more difficult due to the
complexity of patients and higher aesthetic expectations. Since age, pregnancy and weight
changes directly affect the breast tissue and size, it is usually necessary to provide correction
of the affected and unaffected breast after a certain period of time. For mild cases, implants
with or without additional lipofilling may provide satisfactory results, but in the long term it
is necessary to thoroughly inform the patient of the potential necessity of additional
correction procedures such as mastopexy or breast reduction surgery.
Keywords:Poland syndrome, implant, flap, chest asymmetry