Plastic Surgery

Navigating the Map: Classifications and Subtypes

At a Glance

Doctors use classification systems like TBN (Thorax, Breast, Nipple) and Foucras to describe the specific physical differences in Poland syndrome. These systems act as a surgical roadmap to help surgeons determine the right reconstructive techniques and the number of surgeries needed.

Poland syndrome is not a “one-size-fits-all” condition. Because the physical differences can range from a missing muscle to complex rib and hand anomalies, doctors use standardized classification systems to describe exactly what they see. These systems are not just medical labels; they are “surgical roadmaps” that help your care team decide which techniques to use, how many surgeries may be needed, and when those procedures should happen ^[1]^[2].

The TBN and TBNS Systems

The most common way surgeons evaluate Poland syndrome is by looking at three specific areas of the chest: the Thorax, the Breast, and the Nipple-Areola Complex (NAC). This is known as the TBN system ^[1].

T (Thorax): This describes the muscle and bone structure.
- T1: Only the pectoralis muscle is missing.
- T2-T3: The chest wall has slight to moderate depressions.
- T4: There are significant rib or breastbone (sternum) deformities ^[1].
B (Breast): This measures how much breast tissue is present, ranging from B1 (underdeveloped) to B2 (completely absent) ^[1].
N (Nipple): This is critical for surgical planning.
- N1: The nipple is in a near-normal position.
- N2-N3: The nipple is significantly shifted or entirely absent ^[1].

When hand or arm differences are also present, doctors add an “S” (for Syndactyly or hand involvement) to create the TBNS system ^[3]. This ensures that hand specialists are brought into the care team early, as hand procedures often happen much earlier in childhood than chest reconstruction.

The Foucras Classification: Predicting the Journey

While the TBN system describes “what” is missing, the Foucras classification (Levels I, II, and III) helps predict the “intensity” of the treatment. Research shows that a higher Foucras level—indicating more complex involvement of the ribs and muscles—is directly linked to a higher number of surgical procedures required to reach the desired outcome ^[2]. Understanding your Foucras level can help you set realistic expectations for the long-term treatment plan.

How Classifications Guide Care

These systems help your surgeon choose the right “tools” for the job based on the specific anatomy:

Feature	Surgical Approach Guided by Classification
N1 (Minor Nipple Shift)	Often managed with a one-stage procedure, such as a single implant ^[1].
N2/N3 (Major Nipple Shift)	Typically requires a two-stage approach. First, a tissue expander is used to gently stretch the skin, followed by a permanent implant later ^[1].
T3/T4 (Rib Deformities)	May require custom 3D-printed implants or specialized prostheses to fill deep depressions that a standard implant cannot fix ^[4].
B1/B2 (Breast Tissue)	Often treated with fat grafting (taking fat from one part of the body and moving it to the chest) to create a natural look or hide the edges of an implant ^[5]^[6].

The Importance of Stability

Regardless of the classification, most major chest reconstructions are deferred until the end of adolescence. Surgeons look for physical stability—usually defined as two consecutive check-ups where breast and chest measurements have stopped changing—to ensure the reconstruction remains symmetrical as the body matures. This timeline is especially crucial for females, where breast maturity may not be complete until late adolescence ^[3]^[4].

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Common questions in this guide

What is the TBN classification system for Poland syndrome?

The TBN system is a tool doctors use to evaluate three specific areas of the chest: the Thorax (muscle and bone), Breast tissue, and Nipple position. It helps surgeons understand exactly what tissue is missing or altered to plan the best reconstructive approach.

What does the 'S' stand for in the TBNS system?

The 'S' stands for syndactyly, which involves fused or webbed fingers. Doctors use the TBNS system when Poland syndrome involves both chest differences and hand or arm anomalies, ensuring a hand specialist is involved early in your care.

How does the Foucras classification affect my treatment?

The Foucras classification measures the complexity of rib and muscle involvement. A higher Foucras level generally means that more surgical procedures will be needed over time to achieve the best possible reconstructive outcome.

When is the best time to have chest reconstruction surgery for Poland syndrome?

Major chest reconstruction is typically delayed until the end of adolescence when the body has stopped growing. Waiting for physical stability ensures that the reconstructed chest remains symmetrical as the body fully matures.

Will I need a tissue expander before getting a chest implant?

If your nipple position is significantly shifted or absent, your surgeon may recommend a two-stage approach. This often begins with a tissue expander to gently stretch the skin, followed by the placement of a permanent implant in a later surgery.

Curated prompts to bring to your next appointment.

1.Based on the TBN system, what is the 'score' for my or my child's thorax, breast, and nipple?
2.Does the N (Nipple) classification suggest we will need a one-stage or a two-stage surgical process later in life?
3.Is the S (Syndactyly) part of the TBNS system applicable here, and should we consult a hand specialist now?
4.How does the Foucras class for this case impact the number of surgeries we should expect in the future?
5.At what point in adolescence do you typically determine that growth has stabilized enough for reconstruction?

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References (6)

1
Proposal of the TBN Classification of Thoracic Anomalies and Treatment Algorithm for Poland Syndrome.
Romanini MV, Torre M, Santi P, et al.
Plastic and reconstructive surgery 2016; (138(1)):50-58 doi:10.1097/PRS.0000000000002256.
PMID: 27348639
2
Approach to the Pediatric Poland Syndrome Patient: A 20-Year Academic Experience and Update of the Literature.
Perla G, Mah'moud M, Jackson O, et al.
Annals of plastic surgery 2025; (94(4S Suppl 2)):S194-S202 doi:10.1097/SAP.0000000000004320.
PMID: 40167071
3
Poland Sequence: Retrospective Analysis of 66 Cases.
Manzano Surroca M, Parri F, Tarrado X
Annals of plastic surgery 2019; (82(5)):499-511 doi:10.1097/SAP.0000000000001772.
PMID: 30985341
4
Consensus based recommendations for diagnosis and medical management of Poland syndrome (sequence).
Baldelli I, Baccarani A, Barone C, et al.
Orphanet journal of rare diseases 2020; (15(1)):201 doi:10.1186/s13023-020-01481-x.
PMID: 32758259
5
Surgical Algorithm of Poland Syndrome Based on Thorax, Breast, and Nipple-areola Complex Classification.
Romanini MV, Forlini V, Valle M, et al.
Plastic and reconstructive surgery. Global open 2024; (12(11)):e6261 doi:10.1097/GOX.0000000000006261.
PMID: 39583780
6
Tuberous Breast and Poland Syndrome: An Underestimated Association?
Forlini V, Franchelli S, Romanini MV
European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie 2025; (35(1)):9-14 doi:10.1055/a-2494-7611.
PMID: 39626778

This page explains Poland syndrome classification systems for educational purposes. Your surgeon and care team are the best sources for interpreting your specific classification and determining your optimal surgical plan.

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