Standard imaging-guided chest wall perforator flap reconstruction without intraoperative handheld Doppler for granulomatous lobular mastitis: a simplified approach for resource-limited settings

Introduction

Granulomatous lobular mastitis (GLM) is a challenging inflammatory breast disease originating from breast lobules. It typically presents as a rapidly enlarging mass that may progress to abscess formation, skin ulceration, scarring, and nipple retraction. The incidence of GLM has increased significantly, imposing a substantial disease burden in developing countries such as China (1). Women with prolonged GLM episodes have a higher risk of developing breast cancer (2). Currently, no standardized treatment protocol exists for GLM, and each available modality has distinct advantages and limitations. For instance, traditional Chinese medicine and antibiotics are associated with prolonged treatment courses and high recurrence rates. The clinical use of corticosteroids, immunosuppressants, and anti-tuberculosis drugs is often limited by adverse toxic effects (3-5). Surgical intervention, including simple lumpectomy, extended mass resection, and segmentectomy, can shorten the disease course and reduce recurrence; however, these procedures often result in large tissue defects and unsatisfactory cosmetic outcomes (6-9).

Recently, the widespread application of imaging modalities has facilitated the development of breast-conserving techniques (e.g., volume displacement and volume replacement) for managing defects following GLM resection. Volume displacement is suitable for patients with large breasts but not for most Asian women and a subset of Western women with small breasts (10). In the latter cases, volume replacement techniques play a pivotal role (11,12). Previous studies have reported that breast deformity following GLM surgery could be partially corrected using random breast dermo-glandular flaps, which are pedicle flaps consisting of cutaneous, subcutaneous, and mammary gland tissues (13,14). Nevertheless, the T-shaped, pear-shaped, and butterfly-shaped incisions used in such procedures would leave conspicuous scars. Similarly, advancement flaps and latissimus dorsi flaps are associated with extensive scarring (15). In our previous clinical experience, extended mass resection combined with chest wall perforator flap (CWPF) reconstruction has been used to fill tissue defects, preserve breast appearance, and conceal surgical incisions in GLM patients.

Several strategies have been reported for perforator localization in CWPF reconstruction, including preoperative color Doppler ultrasound assessment and no-Doppler flap elevation techniques (16,17). However, the role of multimodal preoperative imaging in GLM patients undergoing immediate CWPF reconstruction, together with clinical outcomes, cosmetic results, and patient-reported satisfaction, has not been fully clarified. To overcome these barriers, we developed a refined surgical approach designed to simplify CWPF reconstruction by avoiding intraoperative handheld Doppler localization while maintaining surgical efficacy. This modified technique represents a shift from real-time intraoperative device dependence to meticulous intraoperative identification of reliable anatomical landmarks, which are preoperatively delineated and mapped using comprehensive cross-sectional imaging. Specifically, magnetic resonance imaging (MRI) offers high-resolution visualization of soft tissues and neurovascular relationships, computed tomography (CT) provides detailed osseous structures for fixed reference points, and ultrasound aids in dynamic assessment.

In this paper, we demonstrate that extended mass resection combined with CWPF reconstruction without intraoperative handheld Doppler achieves superior cosmetic outcomes, improved quality of life, and higher patient satisfaction in GLM patients. This article details the surgical protocol and presents comparative clinical outcomes. We present this article in accordance with the STROCSS reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0196/rc) (18).

Methods

Study design and patient selection

All GLM patients who underwent surgical treatment by the same surgical team between January 2022 and May 2024 at Changzhou No. 2 People’s Hospital, The Third Affiliated Hospital of Nanjing Medical University, were enrolled. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective cohort study was approved by the Ethics Committee of Changzhou No.2 People’s Hospital, The Third Affiliated Hospital of Nanjing Medical University (No. KY204-01). Written informed consent was obtained from all GLM patients prior to study participation and for the publication of relevant clinical images, where applicable.

Due to the retrospective nature of this study, the choice of reconstructive surgery was not randomized. The decision to perform immediate CWPF reconstruction was made jointly by the surgical team and the patient after comprehensive preoperative evaluation. CWPF reconstruction was generally considered when complete excision of the inflammatory lesion was expected to cause an obvious volume defect, contour deformity, nipple-areola displacement, or an unsatisfactory cosmetic outcome after primary closure alone. Key factors included lesion location, estimated resection volume, breast size, skin and soft-tissue condition, patient preference for breast shape preservation, and the presence of a suitable local perforator flap on preoperative imaging. Reconstruction was not routinely performed when the expected defect was small, primary closure was considered cosmetically acceptable, no reliable perforator or adequate donor tissue was identified, the patient declined reconstruction, or additional reconstructive procedures were considered inappropriate. Therefore, the reconstruction group reflected real-world clinical decision-making rather than randomized allocation, and this potential selection bias was taken into account when interpreting the results.

According to international multidisciplinary consensus, first-line recommendations for treatment-naïve GLM patients without abscesses include oral corticosteroids and antibiotics (19). Patients with relapsed GLM, limited response to conservative treatments, or poor medication compliance were enrolled in this study.

Inclusion criteria

• Pathological diagnosis of GLM confirmed by core needle biopsy;
• Localized single lesion or multifocal lesions involving less than three-fourths of the ipsilateral breast quadrants;
• Presence of at least one of the following: (I) refractory to conservative treatments, including close observation and medication for at least 2 weeks; (II) recurrence after abscess drainage or fistulectomy; (III) recurrence after resection of inflammatory lesions, including simple lumpectomy and extended mass resection;
• Complete medical records available and no severe comorbidities.

Exclusion criteria

• Acute infection or tuberculosis;
• Pregnancy or pathological diagnosis of breast cancer;
• Inflammatory lesions involving nearly all quadrants of the ipsilateral breast;
• Complicated with severe systemic disease or other granulomatous diseases, such as Wegener’s granulomatosis, sarcoid-like granulomatous reactions, and foreign body granulomas;
• Refusal to participate in the study.

Based on the above criteria, a total of 80 GLM patients were enrolled. After being fully informed of the study design, they were assigned to two surgical groups: Group A (n=43, flap reconstruction group) underwent extended mass resection with CWPF reconstruction without intraoperative handheld Doppler, and Group B (n=37, no reconstruction group) received conventional surgical treatment (simple lumpectomy, extended mass resection, or breast segmentectomy) without defect reconstruction. Preoperative patients’ characteristics and treatment outcomes were recorded for retrospective analysis. Additionally, patients in Group A underwent routine preoperative contrast-enhanced breast MRI and CT, and relevant data were collected.

Digital imaging

The perforator flap technique still faces several challenges, primarily related to vascular variations among patients. Previous reports have identified six origin patterns of the lateral thoracic artery (LTA), with the majority arising from the thoracoacromial artery (Type I, 67.62%). Variations also include axillary, thoracodorsal, subscapular, or multisource origins, as well as complete absence (20). Therefore, vessel selection and flap harvest site determination remain challenging. Nevertheless, these vessels, their variations, and optimal locations can be identified via routine preoperative imaging, providing valuable guidance for intraoperative decision-making.

MRI

All breast MRI examinations were performed using a 3.0 T Philips Ingenia Elition X scanner (Release 6.1). Patients were positioned prone with both arms elevated above the head. Gadoterate meglumine was administered intravenously at 0.1 mmol/kg body weight, followed by a 20 mL saline flush at 3 mL/s.

Contrast-enhanced subtracted images were analyzed using multiplanar reconstruction to identify images with the highest signal intensity of target vessels. Optimal vascular morphology was visualized on images obtained during the early phase (60–180 seconds after contrast administration). The anatomical relationships among the thoracoacromial artery, axillary vessels, thoracodorsal vessels, and subscapular vessels were clearly demonstrated (Figure 1). This allowed identification of potential vascular variations, thereby distinguishing whether the cutaneous perforators originate from the lateral intercostal arteries (LICAs) or the LTA, and ultimately supporting surgical decision-making (21). Images with the highest signal intensity were selected to document the anatomical courses of vessels. Conventional imaging frequently yields suboptimal visualization of axillary vascular segments and adjacent tissues due to coil-related signal attenuation, whereas positional variations during scanning may introduce spatial registration errors.

Figure 1 Preoperative MRI findings. (A) Representative axial MIP image showing bilateral vascular anatomy, including the AICAP (white arrowhead), LICAP (thin white arrow), SA muscle, and LD muscle. (B) Representative image demonstrating the lateral thoracic artery (thick white arrow) communicating (curved white arrow) with the LICAP (thin white arrow). (C) Three-dimensional volume rendering overview of the anterior chest wall vasculature. Key structures are highlighted: LTA (thick white arrow), a perforator with characteristic arborising “crows feet” morphology (thin white arrow), and the connection between the lateral intercostal artery and LTA (curved white arrow). (D) Sagittal/oblique MIP image showing the specific origin of the perforator emerging from the deep fascia. The intercostal perforator vessel exiting the chest wall is clearly visualized (red circle). AICAP, anterior intercostal artery perforator; LD, latissimus dorsi; LICAP, lateral intercostal artery perforator; LTA, lateral thoracic artery; MIP, maximum intensity projection; MRI, magnetic resonance imaging; SA, serratus anterior.

CT

The COVID-19 pandemic has established preoperative CT imaging as a routine component of many surgical workflows (22). In this cohort, CT images were obtained as part of routine preoperative assessment and were incorporated into surgical planning to identify fixed skeletal landmarks, including rib levels and intercostal spaces. From technical and clinical perspectives, CT scanning offers an advantage in surgical planning owing to its clarity in delineating anatomical landmarks. Unlike other imaging modalities, CT provides precise visualization of ribs and intercostal spaces, equipping surgeons with a fixed reference system crucial for chest wall surgery (23). Based on sagittal view images, intercostal vessels can be visualized penetrating the thoracic wall at specific intercostal spaces (e.g., ribs 3–7) to supply the chest wall (Figure 2). This delineation of anatomical structures enables accurate determination of the rib level (e.g., 4th or 5th intercostal space) from which the dominant perforator originates, thereby facilitating preoperative confirmation of the perforator’s trajectory and deep origin.

Figure 2 Preoperative CT findings. (A) Representative axial CT image clearly delineating anatomical landmarks relative to soft tissue; the arrow indicates the exit point of the intercostal perforator from the chest wall, identified at the 4th or 5th intercostal space based on overall CT assessment. (B) Three-dimensional volume rendering reconstruction. Arrows indicate intercostal perforators penetrating the thoracic wall at specific intercostal spaces, facilitating identification of the dominant perforator’s exact origin level (e.g., 4th or 5th intercostal space). CT, computed tomography; LICAP, lateral intercostal artery perforator.

When CT is already available from routine preoperative assessment, its skeletal landmark information may provide practical support for perforator mapping in resource-limited settings. However, CT should be used selectively when additional scanning is required, because its cost and radiation exposure must be considered.

Color Doppler ultrasound

Based on preliminary assessments from the aforementioned cross-sectional imaging (MRI and CT), the precise vascular course and location were routinely confirmed and marked on the skin surface using preoperative color Doppler ultrasound (Figure 3).

Figure 3 Routine preoperative color Doppler ultrasound for final perforator localization. Representative image showing subcutaneous tissue layers, where colored blood flow signals (red/blue areas) clearly identify the intercostal perforator emerging from the deep fascia. This visualization enables precise identification and surface marking of these vascular structures preoperatively.

The use of color Doppler ultrasound in the preoperative clinic or holding area allows visualization and mapping of distinct blood flow signals. This approach enables precise identification and accurate localization of small vascular structures, particularly intercostal perforator vessels, which are then marked on the skin surface. This crucial step provides a reliable guide for subsequent flap harvesting.

Preoperative imaging planning employed a multimodal strategy to progressively narrow the focus: MRI initially detected and characterized potential perforator vessels and their relationships with adjacent structures; CT estimated the perforator’s intercostal level and assessed the overall anatomical landmarks; and preoperative ultrasound performed final localization and detailed skin marking before incision. This comprehensive strategy was essential for ensuring reliable intraoperative flap harvesting.

Surgical technique: perforator flap reconstruction

Position

General anesthesia was administered. The patient was placed in the supine position, with the affected upper limb abducted to approximately 90° and secured on a padded arm board to ensure adequate exposure of the breast and lateral thoracic wall for flap harvesting.

Surgical steps (Figure 4)

Figure 4 Intraoperative views of the surgical procedure. (A) Preoperative marking and flap design. (B) En bloc resection of the GLM lesion. (C) Surgical defect remaining after excision. (D) Incision for perforator flap harvest. (E) Dissection and identification of the perforator vessel emerging from the deep fascia. (F) Mobilization of the perforator flap and de-epithelialization. (G) Transposition of the flap into the defect for volume restoration. (H) Immediate postoperative appearance following layered closure. GLM, granulomatous lobular mastitis.

Preoperative planning and landmark delineation

• Lesion mapping: based on preoperative ultrasonography and mammography, the precise location and extent of the lesion were identified and marked on the patient’s skin using sterile markers.
• Flap selection: the local perforator flap was selected based on defect location: the lateral intercostal artery perforator (LICAP) flap could fix lateral third breast defects, the anterior intercostal artery perforator (AICAP) flap covers defects over the entire lower mammary pole, and the medial intercostal artery perforator (MICAP) is used for the repair of medial inferior and central breast defects. When the above patterns are unable to be fixed or multiple lesions occupy nearly three-fourths of the ipsilateral breast, different intercostal artery perforator flaps are employed to ensure better flap perfusion and breast appearance (24-27).
• Vascular delineation: using multimodal preoperative imaging, the surgeon marked the planned flap harvest site and mapped the dominant perforator vessel course to optimize vascular supply and ensure flap viability (Figure 5).
  

  Figure 5 Schematic representation of flap design and anatomical distribution of the sixth lateral intercostal artery perforator.

Lesion resection

• Surgical incision: the incision was selected to follow the natural breast contour and Langer lines, prioritizing aesthetic outcomes. Common approaches included periareolar, arcuate, or radial incisions, chosen based on lesion location and distribution.
• Layered dissection: meticulous, sequential dissection of tissue planes (skin, subcutaneous fat, glandular layers) was performed to achieve optimal exposure and precise access to the lesion while preserving surrounding healthy parenchyma.
• Complete resection and cavity management: The lesion was excised en bloc with wide, clear margins under direct visualization and intraoperative palpation. The resulting cavity was irrigated sequentially with hydrogen peroxide and povidone-iodine solutions for sterilization and residual cell clearance, followed by copious sterile saline irrigation to neutralize irritants. The cavity was temporarily covered in preparation for reconstruction.
• Intraoperative margin assessment: intraoperative frozen section analysis was performed on resection margins to confirm clear margins. Positive margins prompted immediate re-resection until clear margins were achieved.

Flap harvesting

• Flap incision: the flap harvest incision was made along the premarked line, with location determined by flap type: lateral thoracic wall for the LICAP flap, or inframammary fold/medial quadrant for the AICAP flap.
• Deep dissection: dissection was gradually advanced through the subcutaneous layers to the deep fascia, with meticulous hemostasis maintained throughout the procedure.
• Perforator dissection and mobilization: the dominant perforator vessel was meticulously identified and isolated, with careful preservation of the main vascular pedicle. To maximize the arc of rotation and facilitate tension-free transfer, non-essential secondary perforators were carefully divided (debulking or thinning technique) to obtain additional flap length without compromising the main blood supply. Adequate mobilization was confirmed when the entire flap could be transposed to the recipient site without tension or pedicle distortion.
• Flap viability assessment: flap perfusion was primarily assessed by observing uniform, brisk capillary bleeding from the dermal surface, confirming adequate vascular perfusion and viability prior to transfer.

Flap placement and closure

• Flap placement: the mobilized perforator flap was carefully rotated or advanced into the lumpectomy defect to achieve complete volumetric reconstruction, eliminate dead space, and restore breast contour.
• Internal closure: the deep dermal and fatty layers of the flap were secured to the surrounding recipient bed using interrupted 3-0 or 4-0 absorbable sutures to maintain tension-free reconstruction. The donor site was then closed, typically by securing the inferior margin of the inframammary fold incision (where applicable) to the chest wall.
• Drainage: a closed negative-pressure suction drain was placed when excessive serous drainage was anticipated, or the residual cavity volume was large (e.g., >50 mL), routed away from the reconstructed area.
• Skin closure: skin incisions at both recipient and donor sites were closed in layers, with the outermost layer approximated using subcuticular or running intradermal sutures to optimize cosmetic outcomes.

Postoperative management

• Wound care: patients were closely monitored for flap compromise, hematoma, or infection, with routine wound care and dressing changes performed.
• Suture removal: non-absorbable skin sutures or staples were typically removed 1 week postoperatively.
• Drain removal: the negative-pressure suction drain was removed when the drainage volume was <10 mL over 3 consecutive days.

Patient-reported outcome assessment

Patient-reported subjective outcomes were assessed during postoperative follow-up using a structured questionnaire, as they provide important information beyond objective clinical indicators. This is particularly relevant for benign GLM, in which treatment is not aimed at reducing mortality but at improving postoperative quality of life, preserving breast appearance, and relieving physical and psychological distress. The assessment included short-term recovery, long-term cosmetic change, recurrence, and patient satisfaction. For Table 1, patients classified their postoperative status as “better”, “same”, or “worse” according to prespecified domains. Short-term recovery was evaluated by the number of dressing changes and the time required to resume bathing, while cosmetic change was assessed at the 12-month follow-up based on the patient’s perception of breast shape, contour depression, symmetry with the contralateral breast, nipple-areola position, and scar visibility. Recurrence was determined by clinical examination and imaging findings when necessary. Patient satisfaction was further evaluated using a structured questionnaire adapted from previously published studies on granulomatous mastitis treatment (8,13). As shown in Table 2, this questionnaire covered five domains: breast shape, treatment duration, economic cost, treatment effectiveness, and influence on daily life. Each domain was scored on an ordinal scale, with higher scores indicating greater satisfaction, and the total satisfaction score was calculated by summing the scores across all domains.

Statistical analysis

Statistical analysis was performed using “SPSS version 27.0”. Continuous variables were first tested for normality; those following a normal distribution are expressed as mean ± standard deviation and were compared using the independent samples t-test, while non-normally distributed data are presented as medians (interquartile ranges) and compared via the Mann-Whitney U test. Categorical data are reported as frequencies and percentages (%), with intergroup comparisons conducted using the chi-square test or Fisher’s exact test. Statistical significance was defined as P<0.05.

Results

A total of 80 patients were included in the retrospective analysis: 43 in Group A (flap reconstruction group) and 37 in Group B (no reconstruction group). Preoperative patient characteristics are shown in Table 3. There were no significant differences in the demographic data, clinical manifestations, treatment history, and concomitant medical conditions between groups (all P>0.05). All CWPF flaps were harvested under preoperative imaging guidance without the use of a handheld Doppler device.

Operative-associated data are presented in Table 4. Analysis of intraoperative records and postoperative details indicated that surgery times, blood loss, drainage volumes, and drainage removal times differed significantly between groups (all P<0.001). The overall postoperative complication rate was comparable between groups, mainly involving delayed wound healing, positive bacterial culture, subcutaneous fat liquefaction, incision infection, nipple-areola ischemic necrosis, ecchymosis, or hematoma (all P>0.05).

Patient-reported outcomes are presented in Table 1. For short-term recovery indicators, no significant differences were observed in the number of dressing changes or time to resume bathing between the two groups. At the 12-month follow-up, the recurrence rate was comparable between groups, whereas Group A achieved significantly superior cosmetic outcomes compared with Group B (P<0.001). To prioritize patients’ subjective experiences, all patients completed a structured patient satisfaction questionnaire adapted from previously published studies (8,13). As shown in Table 2, no significant differences were found in treatment time, economic cost, and treatment effectiveness; however, significant differences were observed in breast shape and quality of life between groups (all P<0.001). Additionally, Group A showed a higher total satisfaction score compared with Group B (P<0.001).

Discussion

The management of GLM requires complete excision to reduce recurrence while preserving cosmetic outcomes, especially in younger patients (28,29). This study demonstrates the successful application of CWPF for localized breast reconstruction after GLM excision, providing a simplified, resource-conscious, and reproducible approach. Our findings may expand access to advanced perforator flap surgery in resource-limited centers.

The CWPF is a local perforator flap based on the LTA or medial internal mammary perforator branches, well-suited for breast-conserving surgery (30). It transposes healthy, well-vascularized tissue into the resection defect, restoring breast volume, texture, and contour with superior outcomes compared with non-reconstructive methods (31). Traditionally, the use of the perforator flap has been limited by expensive equipment, specialized training, and intraoperative Doppler requirements (32). This study addresses these barriers by using multimodal preoperative imaging to reduce dependence on costly intraoperative localization devices, shorten the learning curve, and expand the clinical applicability of CWPF.

Breast vascular anatomy is highly variable. For example, the LTA has up to six origin patterns, emphasizing the risk of blind flap elevation (20). Our multimodal imaging protocol addresses this variability on an individual basis and improves surgical safety and predictability. In particular, MRI identifies vessel origin and course; CT localizes perforators relative to skeletal landmarks; and ultrasound provides accurate preoperative skin marking. Our approach avoids intraoperative handheld Doppler localization or laser flowmetry, while retaining preoperative color Doppler ultrasound for final perforator mapping and skin marking. This approach shifts the key localization step from intraoperative device dependence to careful preoperative planning and anatomical landmark-based flap elevation, which may be particularly practical in resource-limited settings.

It should be noted that “Doppler-free” in this study does not mean the complete omission of Doppler-based imaging. Rather, it refers to the avoidance of intraoperative handheld Doppler localization. Color Doppler ultrasound was still used preoperatively for final perforator confirmation and skin marking. The three imaging modalities in our protocol played complementary roles: MRI helped evaluate the inflammatory lesion, soft-tissue involvement, and possible source vessels; CT provided fixed skeletal landmarks, especially the rib level and intercostal space related to the dominant perforator; and preoperative ultrasound allowed final surface marking before surgery. However, this multimodal strategy should not be interpreted as mandatory for every institution. When MRI and ultrasound provide sufficient information, CT may be omitted or used selectively to avoid unnecessary radiation exposure. Conversely, in centers where MRI is not routinely available, CT combined with preoperative ultrasound and careful anatomical landmark assessment may still provide practical guidance for flap design. In addition, although this approach may reduce dependence on additional intraoperative localization devices, we did not perform a formal cost-effectiveness analysis. The cost of preoperative imaging, especially when CT is performed specifically for perforator mapping, should therefore be considered in future studies.

Compared with traditional surgical interventions (simple lumpectomy, extended mass resection, segmental mastectomy), extended mass resection with CWPF reconstruction achieves favorable recurrence control and better cosmetic results. Immediate volume reconstruction reduces contour deformity and wound complications. Moreover, unlike myocutaneous or distant flaps [e.g., transverse rectus abdominis myocutaneous (TRAM), latissimus dorsi], the CWPF is a true local perforator flap that avoids muscle sacrifice, resulting in minimal donor-site morbidity, faster recovery, less pain, and no functional loss (33,34). It is ideal for localized defects not requiring complex distant tissue transfer.

This study has limitations: its retrospective design may introduce selection bias; the sample size is relatively small; minor discrepancies may occur between imaging and surgical positioning; and flap viability was assessed clinically rather than via objective tools such as indocyanine green fluorescence angiography. Future research should include multicenter, prospective studies to validate this simplified protocol. Quantitative aesthetic and quality of life assessments are recommended, and collaboration with radiology departments will help establish a standardized preoperative imaging protocol for perforator flaps.

Conclusions

In conclusion, this study demonstrates that multimodal imaging (MRI, CT, ultrasound) enables accurate preoperative localization of perforator vessels, facilitating CWPF reconstruction without intraoperative handheld Doppler for GLM patients. This streamlined approach improves surgical accuracy, flap viability, and cosmetic outcomes while potentially reducing dependence on additional intraoperative localization devices. It may therefore represent a practical and reliable strategy for breast reconstruction, especially in resource-limited settings.

Acknowledgments

The authors thank Dr. Qi Qian, Dr. Mei Yang, and Dr. Shu-Yang Xu for providing technical assistance.

Footnote

Reporting Checklist: The authors have completed the STROCSS reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0196/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0196/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0196/prf

Funding: This work was supported by grants from the Bethune Medical Foundation (No. RXAJZZL-09), the Wu Jieping Medical Foundation (No. 320.6750.2025-21-23), the Top Talent of Changzhou “14th Five-Year Plan” High-Level Health Talents Training Project (No. 2022CZBJ065), the Changzhou Medical Center (No. CMCB202401), the Jiangsu Provincial Health Commission General Project (No. MQ2024036), the Changzhou Health Commission Scientific Research Project (No. QN202532), and the Research Fund Project for Science and Technology Development of Nanjing Medical University (No. NMUB20240044).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0196/coif). W.C. reports receiving institutional grant support from the Bethune Medical Foundation, Wu Jieping Medical Foundation, Top Talent of Changzhou “14th Five-Year Plan” High-Level Health Talents Training Project, Changzhou Medical Center, Jiangsu Provincial Health Commission General Project, Changzhou Health Commission Scientific Research Project, and Research Fund Project for Science and Technology Development of Nanjing Medical University. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Changzhou No. 2 People’s Hospital, The Third Affiliated Hospital of Nanjing Medical University (No. KY204-01). Written informed consent was obtained from all patients for study participation and for the publication of relevant clinical images, where applicable.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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