| PurposeBased on three-dimensional digital Computed Tomography Angiography(CTA)data,this study aimed to analyze the morphology of the subclavian artery and its branches and the occurrence and characteristics of thoracic malformation in patients with Poland Syndrome and to explore the relationship between unilateral subclavian artery and its branches and the possible pathogenesis of thoracic malformation in Poland Syndrome.Through the three-dimensional digital analysis of anatomical structure of chest wall defect and the latissimus dorsi muscle flap,this study aimed to validate the feasibility of latissimus dorsi muscle flap transfer to repair the absence of pectoralis major in Poland Syndrome.Besides,this study aimed to introduce a technique to reconstruct the chest wall and breast for Poland Syndrome patients with endoscopic latissimus dorsi muscle flap via a single transverse axillary incision and evaluate its safety and effectiveness.Methods1.Based on CTA data collected from 49 patients with Poland Syndrome in Plastic Surgery Hospital from January 2014 to December 2021,threedimensional model reconstruction and three-dimensional digital analysis were performed using Amira software.The morphology of the subclavian artery,vertebral artery and internal thoracic artery(including the length,volume and mean inner diameter of blood vessels)were analyzed,and the relationship between the anatomical morphology of the subclavian artery and its branches and the severity of pectoralis major defect was analyzed by T test.2.CTA data of 49 patients with Poland syndrome admitted to the Plastic Surgery Hospital from January 2014 to December 2021 were analyzed using Amira software for three-dimensional model reconstruction and threedimensional digital analysis.The pectoralis major,pectoralis minor of the healthy side and the latissimus dorsi muscle,the remaining pectoralis major and pectoralis minor muscle of the affected side were segmented.The volume of each muscle flap was calculated and the development and anatomical structure of the thoracodosal artery of the affected side were analyzed statistically to verify the feasibility of latissimus dorsi muscle flap transfer to repair the pectoralis major tissue defect and the surgical design of latissimus dorsi flap assisted by three-dimensional digital technology.3.From January 2015 to December 2018,patients with Poland syndrome were recruited for chest wall reconstruction or breast reconstruction(combined with breast implant)with endoscopically assisted latissimus dorsi muscle flap transfer via axillary transverse incision in Plastic Surgery Hospital.Thoracic and dorsal CTA examination was performed before surgery to locate thoracodosal vessels and evaluate latissimus dorsi muscle on the affected side.The survival of latissimus dorsi muscle flap,chest and back morphology and complications were followed up after surgery.The following data was collected:latissimus dorsi muscle flap area,prosthesis volume,contralateral breast surgery,length of each procedure and drainage time.Visual Analogue Scale of pain was used to evaluate postoperative pain degree.The reconstruction module of Breast-Q scale was used to evaluate the psychosocial wellbeing of female patients,breast satisfaction and the satisfaction with surgical results of all patients.The upper limb function was assessed by the disabilities of the arm,shoulder and hand Scale(DASH)before and after surgery.Paired T test was used to analyze the differences of breast-Q scale and DASH scale scores between patients before and after surgery.Results1.The length of subclavian artery in 49 patients with Poland syndrome was 73.59±15.5 mm,the volume was 1259.47±480.27 mm3,and the average diameter was 2.25±0.35 mm in the affected side.In the healthy side,the length of that was 74.32±16.82 mm.The volume of that was 1254.36±517.04 mm3,and the average inner diameter of that was 2.22±0.37 mm.There was no statistical differences in the length,volume and average inner caliber between the healthy side and affected side.The length of the subclavian artery in patients with complete pectoralis major loss was 67.8±8.41 mm,the volume was 978.6±317.65 mm3,and the average radius was 2.06±0.25 mm.The length of the subclavian artery in patients with partial pectoralis major defect was 74.6±16.29mm,and the volume was 1307±490.12 mm3,the average radius was 2.28±0.36 mm,and there were no statistical differences in the length,volume and average inner caliber of the affected subclavian artery between patients with complete pectoralis major absence and patients with partial pectoralis major defect.2.In 49 patients with Poland syndrome,the length of the affected vertebral artery was 36.05±11.04 mm,the volume was 134.03±51.37 mm3,and the average inner diameter was 1.07±0.22 mm.In the healthy side,the length was 43.71±51.38 mm.The volume was 154.32±64.14 mm3,and the average inner diameter was 1.14±0.19 mm.There was no statistical differences in the length,volume and average inner caliber between the healthy side and affected side.The length of the vertebral artery on the affected side with complete pectoralis major loss was 42.14±19.78 mm,and the volume of the vertebral artery on the affected side was 116.18±41.64 mm3.The average radius of affected vertebral artery diameter was 0.93±0.21 mm,while the length of affected vertebral artery was 35.13±9.23 mm and the volume of affected vertebral artery was 136.73±52.69 mm3,the average diameter radius of the affected vertebral artery was 1.09±0.21 mm in patients with partial pectoralis major defect and there were no statistical differences in the length,volume and average inner diameter of the affected vertebral artery between patients with complete pectoralis major absence and patients with partial pectoralis major defect.3.49 patients with Poland syndrome had a length of 184.27±31.47 mm,a volume of 134.03±51.37 mm3,and an average diameter of 0.64±0.16 mm of the internal thoracic artery on the affected side.Compared with the normal side,the length of that was 194.42±23.99 mm.The volume of that was 154.32±64.14 mm3,and the average inner diameter of that was 0.62±0.1 mm.The length of the internal thoracic artery was 200.5±40.58 mm and the volume of the internal thoracic artery was 362.86±201.1mm3 in the affected side with complete pectoralis major muscle defect.The average diameter radius of the internal thoracic artery on the affected side was 0.69±0.16 mm.While the length of the internal thoracic artery on the affected side of the patients with partial pectoralis major defect was 182.55±30.33 mm,and the volume of the internal thoracic artery on the affected side was 313.50±156.07 mm3.The average diameter radius of the affected side of the internal thoracic artery was 0.65±0.11 mm and there were no statistical differences in the length,volume and average diameter of the affected side of the internal thoracic artery between patients with complete pectoralis major defect and patients with partial pectoralis major defect.4.In Poland Syndrome,the incidence of dysplasia or absence of pectoralis minor,serratus anterior and latissimus dorsi was high.Among the 49 patients with Poland Syndrome,28.6%of them had total pectoralis major loss and 71.4%of them had partial pectoralis major loss.The total pectoralis major loss was 230.5±91.6 cm3 and partial pectoralis major loss was 165.5±78.6 cm3.The latissimus dorsi tissue was dysplastic in 26.5%of patients with Poland Syndrome,and well developed in 73.5%of patients with latissimus dorsi with a muscle tissue volume of 301.5±108.2 cm3.The muscle tissue volume of latissimus dorsi muscle in patients with lateral latissimus dysplasia was 172.2±97.8 cm3,only 57.1%of that in normal patients.In 49 patients with Poland Syndrome,the volume of latissimus dorsi muscle on the affected side was generally larger than that of pectoralis major muscle on the healthy side,with a volume difference of 33.8±63.9 cm3.The average volume of latissimus dorsi muscle on the affected side was less than that of pectoralis major muscle on the healthy side,and the difference between the two was-48.4±50.2 cm3.The average volume of latissimus dorsi muscle on the affected side was greater than that of pectoralis major muscle on the healthy side in 79.6%of patients,and the difference between the two was 54.8±48.4 cm3.5.49 patients with Poland Syndrome had an average diameter of 0.59±0.21mm of the beginning of the thoracodosal artery on the affected side and 0.61±0.17 mm on the healthy side,with no statistical difference between the affected and healthy side.In 65.3%of patients,the average diameter of the beginning of the affected side of the thoracodosal artery was greater than or equal to the average diameter of the beginning of the healthy side of the thoracodosal artery,with a difference of about 0.1mm.In 34.7%of patients,the average diameter of the beginning of the affected side of the thoracodosal artery was less than the average diameter of the beginning of the healthy side of the thoracodosal artery,with a difference of about 0.25mm.8.1%of the patients had dysplasia at the beginning of the thoracodosal artery on the affected side.The average inner diameter of the dysplasia side was 0.9±0.25 mm,the average inner diameter of the normal side was 0.43±0.06 mm,and the difference of the average inner diameter between two sides was 0.47mm.6.28 patients,including 11 males and 17 females,received endoscopically assisted latissimus dorsi muscle transfer via the axillary incision to repair the chest wall malformation and reconstruct the breast.The area of transferred latissimus dorsi muscle flap was 437.2±110.0 cm2 and the size of silicone prosthesis for breast reconstruction was 240.4±46.0 ml.It took 69.0±13.9 minute to harvest the latissimus dorsi muscle,32.8±6.0 minute to create the anterior chest wall space endoscopically and the total operation time was 169.4±16.1 minute.The duration of drainage was 7.6±1.4 day.Two patients received contralateral endoscope-assisted prosthesis augmentation mammoplasty through axillary incision,and two patients received contralateral breast fat grafting.One patient had mild axillary wound dehiscence.One patient had seroma in the back after removal of drainages.Mild malposition of transferred latissimus dorsi flap was noted in one patient six months after surgery.The rest patients recovered well postoperatively without the following complications:muscle flap necrosis,hematoma,infection,transfer to open surgery,implant capsular contracture,implant malposition,implant rupture.The pain score gradually decreased daily after surgery within one week.The score of breast satisfaction and psychosocial well-being of female patients in breast-Q scale after surgery were significantly higher than those before surgery.All patients were satisfied with the results of surgery.The DASH score showed no significant impairment of upper limb function after surgery.Conclusions1.There were no significant differences in the length,volume and caliber of the vessels of the subclavian artery and its branches in the affected side and normal side in patients with Poland Syndrome and there was no correlation between the abnormalities of the subclavian artery and its branches and the severity of pectoralis major muscle defect.Therefore,the interruption of blood flow of the subclavian artery and its branches were probably not the cause of the thoracic malformation of Poland syndrome.The SASDS(Subclavian Artery Supply Disruption,SASDS)hypothesis was not able to explain the causes of chest malformation in Poland syndrome.2.Three-dimensional CT reconstruction can accurately quantify pectoralis major defect and latissimus dorsi muscle in Poland Syndrome,which plays an important role in the selection of indications for pectoralis major reconstruction surgery using latissimus dorsi muscle flap.The thoracodosal artery of the affected side is normal in patients with Poland Syndrome,and in most patients the latissimus dorsi muscle is large enough to reconstruct the pectoralis major.3.Endoscopy assisted latissimus dorsi transfer through axillary transverse incision provides a safe and effective method for chest wall reconstruction and breast reconstruction in patients with Poland syndrome,with good postoperative aesthetic effect,low complication rate and high patient satisfaction. |
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