poland 's syndrome ( ps ) is characterized by unilateral chest wall and upper - limb abnormalities . the incidence is more in male than in female , with a ratio of about 3:1 . the etiological hypothesis is identified in vascular origin : the unilateral hypoplasia is due to defective blood supply in subclavian arteries or their branches around the 6 week of embryologic development . the operative reconstruction of the chest wall is based on anatomy , degree of severity and gender . several treatment options have been described for chest wall reconstruction in male patients , including the use of prosthesis , local or free flap such as latissimus dorsi muscle transfer , partial latissimus dorsi flap , a rectus abdominis muscle transfer , laparoscopically harvested omental flap , and free anterolateral thigh perforator flap . reconstruction using implant or tissue expander combined with flap and autologous fat injection are also common treatment options . the purpose of this case report is to present our technique using free gracilis flap ( fgf ) as autologous filler in patient with ps after prosthesis explantation , to obtain a good shape with minimal scarring , and donor site morbidity . a 47-year - old male patient presented with unilateral breast and chest wall asymmetry from the absence of the anterior axillary fold and subclavicular hollowing on the left side . the patients were examined , and clinical as well as radiological findings ( rx / tac ) were recorded [ figure 1 ] . only the pectoralis major muscle was missing on the left side , and a hypoplasia and dislocation of the nipple - areolar complex was present without other anomalies . no respiratory or functional impairment due to this deformity the patient underwent an aesthetic surgery 25 years before , for placement of a silicon implant , but he developed a hard capsular contracture [ figure 2 ] . the visual analogue scale ( vas ) the indication for surgical treatment was not only cosmetic but also functional as the capsular contracture was painful . when the implant was removed [ figure 3 ] a gracilis muscle free flap was performed to improve the appearance of the chest wall . the postoperative course were uneventful , and the patient left our hospital after 6 days . a clearly improved appearance was observed without any significant donor site morbidity . the gracilis flap survived . no controlateral procedure was necessary as we did not observe any significant asymmetry [ figure 4 ] . preoperative picture , note the baker 4 contracture computed tomography scans , chest wall with evidence of the prosthesis extrusion neurorrhaphy gracilis motor branch with superficial intercostal nerve in this case report , we report our experience treating a male patient with ps using a fgf . the key problem was mainly aesthetic , and the surgical procedure was chosen for its minimal donor site morbidity and scarring . we were able to correct successfully the aesthetic deficiency of the chest wall and the anterior axillary fold using this method . several techniques have been used to correct deformities associated with ps , with each method featuring advantages and disadvantages . a benefit of chest wall implants ( customised or not ) is that , they are quickly inserted through a relatively small incision and are associated with very little scarring . their use seems very convenient , but the limitation of implant use is that , the prosthesis does not solve the problem of the absent humoral insertion of pectoralis major , which create an anterior axillary fold . implant intolerance , the need of implant removal as well as postoperative displacement are further complications reported with the use of chest wall implants in male patients with ps . chest wall reconstruction with a latissimus dorsi flap is favorable because it can reconstruct the anterior axillary fold . even when using an endoscopically assisted approach , this method requires the transfer of an important muscle of the arm and diminishes the ipsilateral posterior axillary fold and back region . the latissimus dorsi muscle may be hypoplastic or absent in patients with this syndrome , and the use of this method may not always be reasonable . recently reported on a patient with a moderate form of ps who underwent chest reconstruction with a free anterolateral thigh perforator flap , a method that is quickly feasible and associated with little scarring in the axillary region . to us , the distinctive long scar at the donor site speaks against this treatment option . the advantage of our method using a gracilis flap is that besides the immediate reconstruction of the chest contour and the anterior axillary fold , our method results in less scarring and insignificant donor site morbidity on a relatively unremarkable spot . a review of the literature confirmed the minimal functional and aesthetic donor - site morbidity after gracilis - flap reconstruction . moreover , end - to - end nerve coaptation was performed between the gracilis motor branch and the superficial intercostal nerve to avoid volume loss of muscle tissue resulting from neurogenic atrophy [ figure 5 ] . although we presented only a case report and further evaluation is warranted with a larger series , we believe that a gracilis muscular flap is an optimal option for chest wall and anterior axillary fold correction in male patients with ps . this method combines minimal scarring , insignificant donor site morbidity , and an immediate excellent aesthetic result .
poland 's syndrome ( ps ) is a congenital monolateral deformity that may involve breast , chest wall , and upper limb with different degrees of clinical expressions . in some cases , 
 the problem is mainly cosmetic , and the reconstruction should be performed to achieve minimal scarring and donor site morbidity . 
 the authors describe a case report of a male patient with ps who developed a severe capsular contraction after 25 years implant reconstruction , who was treated after explantation using free gracilis flap ( fgf ) . in this patient , 
 only the pectoralis major muscle was missing . 
 an fgf was performed to reconstruct the anterior axillary fold and the soft tissue defect . 
 there was no flap loss , the patient had a clearly improved appearance of the chest wall , and the pain syndrome was solved . in this case report , we demonstrate our experience with the use of an fgf for chest wall reconstruction in male patients with ps after prosthesis explantation .