Treatment options for Poland syndrome

While not a common disorder in many practices, Poland syndrome is a congenital condition characterized by underdeveloped or absent chest muscles. It often involves missing their pectoralis major in many patients and usually affects just one side of the chest. For these patients, this imbalance not only makes them uncomfortable, but also makes them self-conscious about their appearance.

There are surgical options available for both men and women with Poland syndrome to help balance out their chest, including implants and fat grafting. To learn more about Poland syndrome and the options that are available for patients with this condition, we reached out to ASPS Member Surgeon Karen Horton, MD, MSc, FACS.

ASPS: While not widely recognized among the average patient, Poland syndrome is a congenital condition that affects the structure and appearance of the chest wall, often requiring surgical correction. How often do you see cases of Poland syndrome in your practice?

Dr. Horton: Certainly not every day! I probably meet one to two new patients a year with Poland syndrome. I understand that my website is one of the very few plastic surgeons' websites that specifically lists it as a condition they treat.

ASPS: What are the most common surgical interventions for Poland syndrome?

Dr. Horton: For women, insertion of an implant with additional upper pole (above the nipple and areola) fat grafting to the defect in the collarbone area and upper armpit on the Poland syndrome side, with a balancing breast augmentation, reduction and/or lift and liposuction of the unaffected armpit and bra roll on the other breast.

For men, we usually liposuction the unaffected chest and add fat in the form of fat grafting to the Poland side. Pectoral implants are available for men, but these require a long scar under the breast, and they can have complications including infection, a visible or palpable implant edge and dissatisfaction with the results.

ASPS: Are there any surgical interventions that are not as effective as others in treating this condition?

Dr. Horton: Traditional techniques for Poland syndrome reconstruction included a latissimus dorsi pedicled flap, where the largest muscle of the body is rotated around to the front. This procedure sacrifices a second muscle from the body, where a muscle is already missing in the front, and creates a very long scar on the back. For this reason, it is rarely used.

Other free flap techniques, including the DIEP flap or gracilis muscle (TUG flap) free tissue transfer, have been described, but these techniques create a long scar at the donor site, and they are less well-accepted by younger patients who don't have a lot of extra tissue to use.

As mentioned above, custom-made pectoral or chest wall implants were more commonly used 20 to 40 years ago. These older implants can be associated with a firm, unnatural feel and eventual breakdown, as well as migration on the chest wall. Many of the revisions I do are related to this issue.

ASPS: Are there any differences in how surgeons approach treating male Poland syndrome patients vs female Poland syndrome patients?

Dr. Horton: Female patients are usually more willing to consider the placement of an implant. Men are often more willing to accept some asymmetry if it allows them to remove their shirt at the beach without feeling "deformed" or like their chest is attracting attention due to their congenital asymmetry.

Also, the age at which patients seek reconstruction differs between women and men. I usually see teenage girls in consultation for reconstruction shortly after puberty, as one breast is growing while the other side is not growing as much. They often present for a revision a decade or two later, when asymmetry develops after pregnancy and breastfeeding or other age-related changes to the normal breast occur.

Men, on the other hand, present later in life – often in their 30s when they have a well-paying job and can afford reconstruction, or closer to retirement age. They've spent their career in a dress shirt or uniform and are looking forward to retirement, and want to go shirtless at the beach!

ASPS: How do you determine the best possible approach to balance out the appearance of the chest with your patients?

Dr. Horton: It's important to look at all the layers of the chest wall, as they are usually all affected in Poland syndrome. These layers include the skin and soft tissues, such as the breast, the nipple and areola, the underlying muscles, the ribs, the sternum and other body structures. Sometimes the ribs take more of a vertical, curved orientation rather than extending horizontally outward from the sternum.

There is little that can be done for bony or structural deficits. Some soft tissues can be augmented on the Poland side, but complete creation of asymmetry is rarely achieved.

ASPS: Do you have any advice or best practices for patients who are interested in pursuing surgical treatment to balance out the appearance of their chest?

Dr. Horton: Find a board-certified plastic surgeon who has a great deal of experience with Poland syndrome reconstruction or breast reconstruction using a variety of techniques, including free flaps and fat grafting (not just using implants). Ask to speak to other patients who have had a similar reconstruction and to see all types of results, not just the very best ones.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.