AESTHETIC RESTORATION OF POLAND’S SYNDROME INA MALE PATIENT USING FREE ANTEROLATERAL THIGHPERFORATOR FLAP AS AUTOLOGOUS FILLER

ANDREAS GRAVVANIS, M.D., Ph.D., F.E.B.O.P.R.A.S.,* STEVEN LO, M.A., M.R.C.S., and REBECCA SHIRLEY, M.R.C.S.

We report a case of a male patient with Poland’s anomaly who was reconstructed with a free anterolateral thigh perforator flap. The flapwas used successfully as an autologous filler to recreate the anterior axillary line and correct the chest contour deformity. The use of thefree anterolateral thigh perforator flap is an excellent choice as an autologous filler to correct mild and moderate deformity in male Poland’ssyndrome, carrying low morbidity and leaving both minimal scarring and functional sequelae. VVC 2009 Wiley-Liss, Inc. Microsurgery29:490–494, 2009.

Poland syndrome1 comprises a congenital unilateral ab-

sence of the sternal portion of pectoralis major muscle,

ipsilateral symbrachydactyly, and occasionally other mal-

formations of the anterior chest wall and breast. The cur-

rent theory on the etiology of Poland’s Syndrome is sub-

clavian artery hypoplasia,2 caused by kinking of the ar-

tery during the sixth week of gestation: the stronger the

interaction, the more severe the pathology. Foucras et al.3

introduced a classification in three grades of the forms

affecting the chest wall and breast, and appropriate treat-

ment was proposed according to the degree of involve-

ment. Although the condition is more frequent among

males they rarely seek surgical correction, especially

when they present with mild and moderate deformity.3 In

females the ultimate goal of reconstruction is chest wall

and breast symmetry. Correction thus may involve inser-

tion of customized chest implants,4 transfer of latissimus

dorsi muscle flaps,5–8 autologous rib grafts combined

with a latissimus muscle flap,9 free abdominal flaps10 and

Coleman’s lipofilling.11 Treatment in male patient aims

to restore abnormal muscular contour, secondary to agen-

esis of pectoralis major’s sternal and/or clavicular head,

and also chest wall aplasia in severe forms. In male

patients the use of implants, with or without latissimus

muscle transposition4,12,13 are the established methods in

the literature. Given that the key problem in Poland’s

syndrome is purely esthetic and that it has no functional

impact, the chosen surgical treatment should have mini-

mal morbidity, scarring and functional sequelae. In this

regard we present the use of a free anterolateral thigh

perforator flap as an autologous filler to restore the mus-

cular contour in a male patient with moderate Poland de-

formity.

CASE REPORT

A 16-year-old healthy male presented with unilateral

breast and chest wall asymmetry (see Fig. 1). The sternal

head of the left pectoralis major muscle was absent with

an associated ill-defined anterior axillary fold. Interest-

ingly, the clavicular head of pectoralis major was hyper-

trophic exaggerating the chest wall anomaly. The breast

was hypoplastic and the nipple-areola complex was small

and displaced superolaterally. No hand anomaly was pres-

ent. The latissimus dorsi muscles were symmetric and

well developed. The patient was psychologically dis-

turbed by the esthetic appearance of his chest and

requested surgical correction of the deformity. The

patient was a high level rugby player involved in many

other sporting activities. Consequently, a surgical proce-

dure was planned that would result in minimal donor site

morbidity, least scarring and maximum patient satisfac-

tion. The option of an autologous vascularized tissue to

be used as a filler to recreate the anterior axillary fold

and restore the anterior chest wall contour was therefore

attractive. After thorough discussion about all alternative

options, advantages and disadvantages, risks and possible

complications, we decided to proceed with free transfer

of the anterolateral thigh perforator flap. The volume def-

icit of the left chest wall was estimated by templating the

chest contour defect. The thickness of the defect was esti-

mated 1.5 to 1.9 cm at various sites of the left chest. The

lateral thigh skin thickness was estimated by pinch test

1.6 cm and was considered reasonable match. Although,

the use of CT-scan preoperatively could provide more

precise, scientific calculation of the lost volume of chest

wall, was not proposed to avoid patient’s exposure to

radiation.

The patient was placed in the supine position. A hori-

zontal 5 cm incision was made at the lower axillary

Plastic Surgery Department, Queen Victoria Hospital, Foundation Trust,NHS, East Grinstead, West Sussex, UK

*Correspondence to: Andreas Gravvanis, M.D., Ph.D., F.E.B.O.P.R.A.S.,Queen Victoria Hospital, NHS, Foundation Trust, East Grinstead, HoltyeRoad, West Sussex, RH193DZ, UK. E-mail: gravvani@yahoo.com

Received 11 October 2008; Accepted 7 January 2009

Published online 18 March 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20637

VVC 2009 Wiley-Liss, Inc.

crease and was used both for the recipient vessels and

the subglandular pocket dissection. The thoracodorsal

vessels were dissected free from the thoracodorsal nerve

and were divided proximal to the origin of the serratus

branch. With the aid of a lighted retractor, a subglandu-

lar/subcutaneous pocket was dissected as marked preoper-

atively, using the same axillary incision. The lower bor-

der of the pectoralis major muscle’s clavicular head was

also dissected.

A tandem team raised the ALT flap simultaneously by

a standard dissection technique.14 A straight line was

marked between the anterior superior iliac spine and the

lateral edge of the patella. The midpoint of this line was

identified and a 3 cm radius circle was outlined. Perfora-

tors, which are usually located within this area, were

detected by Color Doppler Ultrasonography preoperatively.

A medial incision above the rectus femoris muscle was

made and deepened down to the subfascial plane. The dis-

section was continued beneath the deep fascia and

extended laterally until the dominant perforator was

encountered. An intramuscular route of the perforator,

through vastus lateralis, was identified. The dissection pro-

ceeded laterally toward the intramuscular space between

rectus femoris and vastus lateralis muscle to identify the

main descending branch of the lateral circumflex femoris

artery (LCFA). The desired size of the flap (7 3 14 cm)

was estimated preoperatively by templating the chest con-

tour defect. This flap template was subsequently marked

and centered over the dominant perforator. The deep fascia

was incised laterally, and the flap was elevated from lateral

to medial until the perforator was encountered. Elevation

of the flap was completed by dissection of the perforator to

the LCFA origin. The pedicle length was 14 cm. The donor

area was closed directly.

The flap was de-epithialized and sutured temporarily on

the chest wall, to mold and orientate the flap for the best

possible contour (Fig. 2A). Key sutures were marked on the

chest and on the flap. Flap inset (Fig. 2B) was performed

with PDS 2–0 sutures, with the upper border of the flap

sutured to the caudal border of the clavicular head of pector-

alis major, towards the crest of the greater humural tuberos-

ity. The lateral circumflex femoral artery and vein were

anastomosed in end-to-end fashion to the thoracodorsal ar-

tery and vein. The upper corner of the flap (2 3 2 cm) was

not de-epethialized and was inset at the axillary incision as

a skin paddle for flap monitoring (Fig. 2C). Recovery was

uneventful and the patient was discharged on day 4.

Three months postoperatively the patient was noted to

have a well developed anterior axillary fold, significantly

improved chest contour and reasonable symmetry with

the controlateral breast (see Fig. 3). Although the skin

paddle was well hidden in the axilla, this was removed at

a second stage under local anesthetic. No donor site prob-

lems were reported by the patient during sporting activ-

ities, and functional evaluation demonstrated full range of

motion at the knee joint without muscle weakness.

Although lipofilling was proposed for further definition,

the patient was satisfied with the esthetic outcome of his

reconstruction and did not wish for further symmetrising

procedures.

Figure 1. Preoperative left anterior (A), left three-quarters (B) and

left lateral (C) view of male Poland syndrome patient demonstrating

chest wall deformities, poorly-defined anterior axillary line, hypertro-

phy of the clavicular head and absense of the sternal head of pec-

toralis major muscle. [Color figure can be viewed in the online

issue, which is available at www.interscience.wiley.com.]

Aesthetic Restoration of Poland’s Syndrome 491

Microsurgery DOI 10.1002/micr

DISCUSSION

The surgical challenges presented by Poland’s syn-

drome depend upon the clinical manifestations, and may

include restoration of muscle contours such as the ante-

rior axillary fold and infraclavicular hollowing, or resto-

ration of the female breast and nipple-areola complex.

Patients seek therapy primarily for cosmetic reasons

given that functional compromise is very rare, even in

the most severe forms of the syndrome with costal defor-

mity. Several strategies have been proposed to achieve

Figure 2. (A) Intraoperative view demonstrating the de-epethilial-

ised perforator flap overlying the chest wall before implantation.

The key sutures were marked on the chest and on the flap. (B)

The flap was buried under the chest skin and PDS 2–0 sutures

were used to secure its position at the marked areas. (C) The

upper corner of the flap (2 3 2 cm) was inset at the axillary incision

for flap monitoring. [Color figure can be viewed in the online issue,

which is available at www.interscience.wiley.com.]

Figure 3. Postoperative left anterior (A), left three-quarters (B) and

left lateral (C) view of male Poland syndrome patient demonstrating

well developed anterior axillary fold, significantly improved chest

contour and reasonable symmetry with the controlateral breast.

[Color figure can be viewed in the online issue, which is available

at www.interscience.wiley.com.]

492 Gravvanis et al.

Microsurgery DOI 10.1002/micr

the reconstructive goals in male patients with Poland’s

syndrome.

Pinsolle et al.11 presented their experience with auto-

logous fat injection in male Poland’s syndrome. They

reported that this treatment can be used alone, or more

commonly in combination with traditional reconstruction

techniques, in all grades of Poland’s syndrome. The

authors concluded that this technique is useful to add vol-

ume and especially to correct the contour defects of this

syndrome such as the subclavicular hollow and absence

of anterior axillary fold. However, in the majority of

cases autologous fat injection was associated with other

reconstruction techniques and more than one lipostructure

sessions were necessary per patient.

Custom made prosthesis have been used with estheti-

cally acceptable results.4,7,13,15 However potential prob-

lems include seroma formation4 and implant displace-

ment.13 Advantages of the implant only reconstructions

include simplicity and fast recovery. Interestingly, the

authors did not report development of capsular contrac-

ture in any case. Nevertheless, these implants are placed

subcutaneously and the likelihood of capsular formation

in long term basis should be emphasized to the patients.

Hester and Bostwick in 19825 reported first, Poland’s

syndrome correction with latissimus muscle transposition

and became the most well-accepted and established

method. Borschel et al.7 improved this method using a

two-stage endoscopically-assisted approach. We further

modified the endoscopic-assisted technique14 ensuring

more predictable result and minimal scarring. Neverthe-

less, the drawback of the procedure is the functional mor-

bidity associated with the muscle harvesting that could be

noticeable in young patients with sport activities.

Marks et al.12 have compared different modalities for

male Poland syndrome correction. Firstly, custom silicone

implants alone; secondly, transfer of an ipsilateral pedi-

cled latissimus dorsi muscle flap with intact thoracodorsal

nerve and without implant; and thirdly, the combination

of the latissimus dorsi and implant. The authors con-

cluded that only patients who had a combination of sili-

cone implant and latissimus dorsi muscle flap had satis-

factory long-term correction of their deformity.

More recently, the DIEAP flap has been used to recon-

struct the chest and the breast in severe forms of female

Poland syndrome.10,16 The use of a perforator flap is very

attractive since it is associated with minimal donor site

morbidity. This could be particularly useful in male manual

workers, and patients involved in sporting activities.

In our case, the treatment was based on the patient’s

moderate deformity and requirement for improvement with

the least scarring and donor site morbidity. Endoscopic har-

vesting and transposition of latissimus dorsi muscle flap

was excluded to minimize functional shoulder deficit that

may have been apparent in this high level rugby player,

and to avoid the resulting asymmetry of his back. The use

of a customized chest wall implant was also rejected by the

patient due to the risk of capsular formation and potential

problems with implant fracture during high contact sports.

Lipofilling was not an option since the patient had insuffi-

cient fat reserves to allow for numerous sessions. The

option to use an autologous vascularized tissue as a filler to

recreate the anterior axillary fold and restore the anterior

chest wall contour was therefore attractive.

Two options were proposed to the patient: free an-

terolateral thigh perforator flap17 and pedicled thoracodor-

sal artery perforator flap.18 Both are associated with neg-

ligible donor site morbidity but with a long scar on the

thigh area and the back, respectively. The patient chose

the thigh area as a donor site since the scar could be eas-

ily covered with a conventional swimming suit. The ALT

perforator flap can ensure negligible donor site morbidity

and acceptable thigh scarring in a male patient.14,17 The

use of a dermo-adiposal perforator flap as a filler in our

case resulted in well defined anterior axillary fold and

addressed the chest contour deformity.

The incorporation of vastus lateralis muscle could

provide more volume to the transferred flap. Its use as

chimeric flap could restore the volume deficit in particu-

lar areas of the chest, planned with the aim of CT scan

preoperatively. Nevertheless, the procedure is associated

with some donor site morbidity, and is technically impos-

sible to estimate precisely the volume of the transferred

muscle. Moreover, the progressive muscle atrophy, due to

dennervation, cannot ensure predictable result. Conse-

quently, we propose the use of a dermo-adiposal perfora-

tor flap in mild and moderate male Poland syndrome,

while the incorporation of part of vastus lateralis muscle

could be used in significant contour defects.

The other significant advantage of the perforator flap

over a musclulocutaneous flap is that they do not show

atrophy over time. Improvements in esthetic definition

can be addressed at a second stage with lipofilling, with

the added advantage that the perforator flap provides a

well-vascularized environment for autologous fat grafts.

Advantages over implant reconstruction are that perfora-

tor flaps remains soft, pliable and natural looking

throughout patient’s life and changes as the patient ages.

In conclusion, the free anterolateral thigh perforator

flap is an excellent choice as autologous filler to correct

mild to moderate deformity of male Poland’s syndrome,

carrying low morbidity, and leaving both minimal scar-

ring and functional sequelae.

REFERENCES

1. Poland A. Deficiency of the pectoral muscles. Guys Hosp Rep1841;6:191–193.

Aesthetic Restoration of Poland’s Syndrome 493

Microsurgery DOI 10.1002/micr

2. Dustagheer S, Basheer MH, Collins A, Hill C. Further support forthe vascular aetiology of Poland syndrome—A case report. J PlastReconstr Aesthet Surg 2008 Jun 19 [Epub ahead of print].

3. Foucras L, Grolleau-Raoux JL, Chavoin JP. Poland’s syndrome:Clinic series and thoraco-mammary reconstruction. Report of 27cases. Ann Chir Plast Esthet 2003;48:54–66.

4. Gatti JE. Poland’s deformity reconstruction with a customized, extra-soft silicone prosthesis. Ann Plast Surg 1997;39:122–130.

5. Hester TR Jr, Bostwick J III. Poland’s syndrome: Correction with latis-simus muscle transposition. Plast Reconstr Surg 1982;69:226–233.

6. Kelly EJ, O’Sullivan ST, Kay SP. Microneural transfer of contralat-eral dlatissimus dorsi in Poland’s syndrome. Br J Plast Surg 1999;52:503–504.

7. Borschel GH, Izenberg PH, Cederna PS. Endoscopically assistedreconstruction of male and female poland syndrome. Plast ReconstrSurg 2002;109:1536–1543.

8. Gravvanis AI, Panayotou PN, Tsoutsos DA. Poland syndrome in afemale patient reconstructed by endoscopically assisted technique.Acta Chir Plast 2007;49:37–39.

9. Haller JA Jr, Colombani PM, Miller D, Manson P. Early reconstruc-tion of Poland’s syndrome using autologous rib grafts combinedwith a latissimus muscle flap. J Pediatr Surg 1984;19:423–429.

10. Liao HT, Cheng MH, Ulusal BG, Wei FC. Deep inferior epigastricperforator flap for successful simultaneous breast and chest wallreconstruction in a Poland anomaly patient. Ann Plast Surg 2005;55:422–426.

11. Pinsolle V, Chichery A, Grolleau JL, Chavoin JP. Autologous fatinjection in Poland’s syndrome. J Plast Reconstr Aesthet Surg 2008;61:784–91.

12. Marks MW, Argenta LC, Izenberg PH, Mes LG. Management of thechest-wall deformity in male patients with Poland’s syndrome. PlastReconstr Surg 1991;87:674–678.

13. Pereira LH, Sabatovich O, Santana KP, Picanco R, Sterodimas A.Surgical correction of Poland’s syndrome in males—A purposelydesigned implant. J Plast Reconstr Aesthet Surg 2008;61:393–399.

14. Gravvanis A, Tsoutsos D, Karakitsos D, Iconomou T, PapadopoulosO. Blood perfusion of free anterolateral thigh perforator flap: its ben-eficial effect in the reconstruction of infected wounds in the lowerextremity. World J Surg 2007;31:11–18.

15. Avci G, Misirlioglu A, Eker G, Akoz T. Mild degree of Poland’ssyndrome reconstruction with customized silicone prosthesis. Aes-thetic Plast Surg 2003;27:112–115.

16. Hamdi M, Blondeel P, Van Landuyt K, Tondu T, Monstrey S. Bilat-eral autogenous breast reconstruction using perforator free flaps: Asingle center’s experience. Plast Reconstr Surg 2004;114:83–89.

17. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have wefound an ideal soft-tissue flap? An experience with 672 anterolateralthigh flaps. Plast Reconstr Surg 2002;109:2219–2226.

18. Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P, Mon-strey S. Surgical technique in pedicled thoracodorsal artery perfora-tor flaps: A clinical experience with 99 patients. Plast Reconstr Surg2008;121:1632–1641.

494 Gravvanis et al.

Microsurgery DOI 10.1002/micr