[Correction of thoraco-mammary deformity of Poland syndrome]

The Breast-Pectoralis Flap: A New Advance in Autologous Breast Reconstruction-A Preliminary Report on 20 Cases

BACKGROUND

In the past, several publications have described breast reconstruction techniques that utilize the contralateral breast; however, interest diminished because of technical difficulty, scarring, and poor aesthetic results.

OBJECTIVES

This study aimed to present a new breast reconstruction technique that uses a combination of the breast-pectoralis flap and the abdominal advancement flap.

METHODS

This retrospective study analyzed the results and complications of 20 consecutive breast reconstructions with the breast-pectoralis flap technique.

RESULTS

The authors present a series of 20 breast reconstructions that utilized the breast-pectoralis flap. Delayed breast reconstruction was performed in 13 cases (65%), breast reconstruction in 5 patients (25%) with Poland syndrome, sequela correction after a chest wall sarcoma in 1 patient (5%), and sequela correction after breast cystic lymphangioma resection in 1 patient (5%). One complication required surgical reintervention without long-term consequences. The outcomes were considered very good in 50% of the cases, good in 45%, and fair in 5%.

CONCLUSIONS

The combination of the breast-pectoralis flap and the abdominal advancement flap is an interesting advance in breast reconstruction. Evaluation of the presented cases suggests wider indications for this technique.

LEVEL OF EVIDENCE: 4

Poland syndrome: Fortuitous discovery of a familial case in Togo

INTRODUCTION AND IMPORTANCE

Poland syndrome is a rare malformative disease. It is characterized by agenesis or hypoplasia of the pectoralis major muscle associated or not with a malformation of the ipsilateral thoracic limb. The authors report the fortuitous discovery of a familial case of Poland syndrome in Togo.

CASE PRESENTATION

He was a 25-year-old young man, with no known pathological history, examined as part of a physical fitness assessment and who presented with thoracic asymmetry. The clinical and radiological explorations made it possible to conclude to a Poland syndrome in its minor form without any other associated malformation. In addition, three other paternal uncles of the patient presented with the same clinical symptomatology. In the absence of a clear indication, the patient received no treatment.

CLINICAL DISCUSSION

Poland syndrome is a rare congenital malformation. The abnormalities encountered are cutaneous-glandular, osteo-cartilaginous and muscular. The etiopathogenesis of the disease is unknown. The diagnosis is clinical and is based on the demonstration of agenesis of the pectoralis major muscle. The disease does not often lead to functional discomfort; therefore the treatment is not systematic and has only aesthetic value.

CONCLUSION

A rare congenital disease, Poland syndrome can occur sporadically or in families. Its treatment depends above all on the psychological repercussion of the disease.

The use of Fat-Augmented Latissimus Dorsi (FALD) flap for male Poland Syndrome correction: a case report

We present a 23-year-old male patient with severe PS, characterized by marked left thoracic wall deformity. Reconstruction was performed using the Fat-Augmented Latissimus Dorsi flap, which was fixed to the chest wall hollowing corresponding to where the pectoralis major muscle was missing. Patient was satisfied with final aesthetic and functional result.

[Lipomodeling for congenital breast deformities: Technique, results and indications]

Congenital breast deformities usually occur during adolescence and can disturb the self-development and affect the identity during this crucial stage. Several surgical techniques are now available to correct these different anomalies. The objective is to clarify the place of lipomodeling in thoraco-mammary malformations, resuming the different indications, the results, as well as the limits and potential complications. The adipose tissue was harvested by soft aspiration as to reduce adipocyte trauma and using a syringe fitted with a 3.5mm cannula. After centrifugation, fat was reinjected retrogradely and by making thin cylinders of fat similar to "spaghetti". Moderate to severe asymmetry is one of the best indications for lipomodeling using one or two sessions. Thus, a perfect and lasting symmetry is achieved, without the need of an implant, which would inevitably leads to asymmetry because of a dissimilar evolution of the breast all over the time. In Becker's nevus syndrome, lipomodeling has also been performant in bluring the hyperpigmentation of the nevus. The role of lipomodeling in pectus excavatum deformity (antero-posterior sternocostal depression) is also crucial. Lipomodeling can be used alone, or in combination with a rigid customed silicone implant. Tuberous breasts include various anomalies. Lipomodeling is currently used especially when the anomaly is unilateral (2 fat graft sessions are usually needed). Fasciotomies are frequently performed too. Lipomodeling is a real revolution in the management of Poland syndrome (anomaly characterized by the unilateral lack of the pectoralis major muscle, more or less associated with other ipsilateral anomalies). On average, 3 to 5 sessions are necessary to obtain a suitable symmetry. Lipomodeling is very unlikely to cause major surgical complications. Cytosteatonecrosis nodules mainly occur with novice practitioner and decrease as they become more experienced. However, the principle of the three-dimensional network, and the phenomenon of tissue saturation of the recipient site should be respected. The main limitation of lipomodeling is directly related to the amount of fat available. That's why it is very important to evaluate it during the first clinical consultation, and to carefully select the patients eligible in order to limit the risk of failure. Lipomodeling of congenital breast anomalies is a technique well established, with a precise algorithm to follow, and is a procedure with low surgical risk, less scarring, cosmetic and lasting results. This technique is to be suggested as a first line treatment in all indications of congenital breast deformities, alone or combined to an implant. Therefore, it seems essential that a plastic surgeon fully master the indications and the use of fat tissue transfer procedure, in order to obtain natural and harmonious results.

[Nipple-areola complex malformations]

THE NIPPLE-AREOLA COMPLEX, ALSO KNOWN AS THE NIPPLE-AREOLA PLATE, IS AN ESSENTIAL VISUAL FEATURE OF THE BREAST.THIS COMPLEX CAN BE AFFECTED BY VARIOUS MALFORMATIONS, BOTH CONGENITAL AND ACQUIRED. ALTHOUGH THESE ANOMALIES OFTEN HAVE A MODERATE IMPACT ON THE FUNCTIONALITY OF THIS COMPLEX, THE RESULTING PSYCHOLOGICAL CONSEQUENCES CAN BE SIGNIFICANT. THEIR TREATMENT IS MOST OFTEN SURGICAL AND MANY TECHNIQUES HAVE BEEN DESCRIBED OVER THE YEARS TO RECONSTRUCT AREOLA AND NIPPLE. REGARDLESS OF THE TECHNIQUE USED, THIS ONE AS TO BE SIMPLE, QUICK, IMITATE AS CLOSELY AS POSSIBLE A NATIVE AREOLA-NIPPLE COMPLEX AND BE RELATIVELY DURABLE, AVOIDING NUMEROUS SURGICAL PROCEDURES.: .

[Poland's syndrome]

Breast and thoracic deformities of Poland syndrome is a rare malformation known to be difficult to treat. Numerous descriptions of surgical corrections have been published but none achieved to correct severe cases before description of lipomodeling technique. The aim of this article is to present thoraco-mammary deformity of Poland syndrome, corrections techniques already available and therapeutical indications in primary and secondary cases. Constant anomaly of Poland syndrome is agenesis of sterno-costal part of pectoralis major muscle but other muscular anomalies can be associated. Skin and glandular anomalies present with a fine skin and an absent or hypoplasic subcutaneous fat with a glandular hypoplasia of various degree. Osteo-cartilaginous anomalies can be associated in very severe cases. Clinical sign of Poland syndrome is forced adduction manoeuvre highlighting pectoralis major agenesis. Functional impact of the deformity is low but psychological and psychosocial implications can be very important, supporting an early surgical correction. Therapeutic means are various and accurate descriptions are given in this article: thoracic bony reconstruction, thoracic implant made of silicone elastomer, breast implant, skin expansion, latissimus dorsi pedicled flap, free flaps, breast lipomodeling, Breast-pectoralis flap. Principles of each technique are described and balanced with their actual use in this malformation. Indications have been completely modified these last years due to lipomodeling contribution which represented a huge step in this deformity treatment. In our practice, if autologous reconstruction with lipomodeling is possible, we choose this solution at first. In case of severe thoracic deformity, a silicone elastomer implant made with the help of computed assisted conception can be an important adjunct, mainly by thin young man. In secondary cases, if implant is well tolerated, we found logical to stay in the same reconstruction path and do one or two sessions of lipomodeling in order to improve reconstruction. If implant tolerance is low and skin very thin at risk of exposure, we do recommend a conversion of implant reconstruction to autologous reconstruction. In conclusion, thoraco-mammary deformities of Poland syndrome are rare and hard to treat and should be managed by well trained and experimented surgeons. Breast lipomodeling is a huge step in the treatment of these deformities and should be regarded, in our opinion, as first line treatment if fat deposits are sufficient. In case of low fat provisions or in the thin young man, composite techniques should be used with silicone elastomer implant.

[Embryology and anatomy of the thorax and breast]

Embryology and anatomy of the chest wall and breast will be developed in this chapter. The walls of the thorax will be described; the anatomical notions of thoracic deformities will be detailed. The anatomy of the mammary gland will be developed around the understanding of the means of fixity and vascularization. The anatomical descriptions come from the writings of ancient anatomists, notably Testut and Latarjet, as well as the iconographies taken from their various works.